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T1696 Reflux Patterns Differ Among Patients With Non-Erosive Reflux Disease (NERD), Hypersensitive Esophagus (HE) and Functional Heartburn (FH)
Sleep time was significantly longer in the A-GERD group (P<0.05). No significant differences were observed in age, body mass index, lipids, liver function, glucose metabolism, exercise habits, or dietary habits between groups. Conclusion: Incidence of A-GERD was lower than that of NERD, but A-GERD was frequently observed in smokers showing mild chronic atrophic gastritis and long sleep time (lying time). Although A-GERD patients showing few dyspepsia or acid reflux symptoms infrequently visit medical institutions and undergo endoscopy, the complication of grade B or higher RE was observed in around one-third of cases.
The Association Between Acid Reflux and Cough in Patients With Cystic Fibrosis is Not Dependent on the Type of Acid Reflux Frederick W. Woodley, John Hayes, Alpa Patel, Karen McCoy, Hayat Mousa Background: Association of acid gastroesophageal reflux (AGER) with cough has been demonstrated in adult patients with cystic fibrosis (CF). We previously showed that use of combined esophageal pH monitoring and multichannel intraluminal impedance (EPM/MII) reveals 4 distinct types of AGER episodes; classic two-phase, single-phase, pH only, and re-reflux AGER episodes. Specific Aim: To investigate the question whether specific types of AGER might predict coughing in CF patients. Methods: 24-hr EPM/MII reports from 27 CF patients (no anti-reflux meds and no fundoplication) were reviewed. Patients for whom analysis demonstrated an association of AGER with cough (co-occurrence within 5-min windows with SAP ≥95%) were analyzed. Total AGER episodes within this subset of patients were divided into AGER types and analyses were repeated. Results: 1) Association of AGER with coughing was detected in 9 of 27 CF patients (5M/4F, median age 18.5yrs, range 6.148.5yrs). 2) Of those selected patients, the mean number of AGER was 133 (Range 69 to 231) in which 28% were two phase, 13% were single phase, 53% were pH only events, and 6% were re-reflux (Friedman p<0.001). 3) The mean percent events associated with cough were 29.4% for two phase, 33.7% for single phase, 24.9% for pH only events, and 32.9% for re-reflux (Friedman p=.31). Summary and Conclusions: While two-phase and pH only episodes occurred more often than single-phase and re-reflux episodes, specific types of AGER did not predict cough. We conclude that all AGER types should be considered when assessing the association of AGER with cough in CF patients.
T1695 Reflux Patterns in Patients With Short and Long Segment Barrett's Esophagus, Erosive Esophagitis and Controls: A Study Using Impedance-pH Monitoring Edoardo Savarino, Patrizia Zentilin, Daniel Pohl, Elisa Marabotto, Giorgio Sammito, Lorenzo Gemignani, Radu Tutuian, Vincenzo Savarino Introduction: Several studies documented higher esophageal acid exposure in Barrett's esophagus (BE) than in other forms of GERD. Differences in composition, migration and clearance of reflux events are currently underinvestigated. Aim: To compare reflux patterns in patients with BE, erosive esophagitis (EE) and controls using 24-hour MII-pH. Methods: One-hundred consecutive patients with BE, 50 with EE and 48 controls underwent MIIpH off-therapy. We quantified distal esophageal acid exposure time (AET), number of reflux episodes (acid, nonacid), mean acid clearance time (MACT), median bolus clearance time (MBCT) and proximal (15 cm above LES) migration of the refluxate. Results: The degree of gastroesophageal reflux increased with respect to the severity of mucosal damage, as shown in the Table. Twenty-five patients (100%) with LSBE, 66 (88%) with SSBE and 40 (80%) with EE had abnormal AET. Total and acid reflux episodes gradually increased from controls to EE, SSBE and LSBE (p<0.01). Weakly acidic reflux events were significantly higher in LSBE and SSBE than in EE and controls (p<0.05). Re-reflux episodes were more common in LSBE (73%) compared to SSBE (63%), EE (43%) and controls (7%). Conclusion: Refluxers with metaplastic epithelium have longer esophageal refluxate (both acid and weakly acidic) exposure time, higher number of total reflux episodes, increased number of re-reflux events and prolonged acid and volume clearance times. Impedance data suggest that the severity of mucosal damage is strictly related to the degree of reflux disease and therefore to the severity of antireflux barrier incompetence. The contribution of weakly acidic reflux to the pathogenesis of BE warrants further investigations.
T1693 High Nitrate Intake May Be Related to GERD: An Ecologic Study Siavosh Nasseri-Moghaddam, Azadeh Mofid, Hadi Razjouyan, Mehdi Nouraie, Reza Malekzadeh INTRODUCTION: GERD is a common disease in Tehran (21.2% of the population). Nitrate content of drinking water has been reported to be higher than recommended values in some parts of Tehran. This motivated us to assess the correlation of nitrate content of drinking water with GERD prevalence in a population-based study. AIMS & METHODS: In this study, a random clustered sample of the city of Tehran permanent households was selected from the latest postcodes. Data were collected by direct interview for each person aged 1865 yr. Frequent GERD was defined as existence of at least weekly episodes of heartburn and/or acid regurgitation during the last 12 months. Data about nitrate content of drinking water in different areas of Tehran was obtained from the regional water organization of Tehran. Odds ratios and 95% CIs were calculated and a multivariable model analyzed. RESULTS: Interview was performed with 2,561 eligible subjects (42.3% men, response rate: 84.8%) and 2,058 (80.4%) were included in the final analysis. The prevalence of frequent acid regurgitation, infrequent acid regurgitation, frequent heart burn and infrequent heart burn were 15.7%, 25.5%, 10.7% and 11.8% respectively. Nitrate levels in drinking water were as follow: 20.0% areas with nitrate level under 50mg/dl, 62.1% areas with nitrate level between 50l and 75mg/dl, 15.0% areas with nitrate level of 75-100mg/dl, and 2.9% areas with nitrate level more than 100mg/dl. Individuals living in areas with drinking water containing more than 100mg/dl nitrate were more likely to experience frequent acid regurgitation than people who lived in areas with water containing less than 100mg/dl nitrate (29.2% vs. 15.3%, OR 2.88, 95% CI: 1.24-6.68, p value: 0.01). After adjustment for sex, age, education level, smoking, BMI, NSAID consumption, positive family history for GERD and positive spouse history for GERD, the correlation remained significant. We repeated this analysis for infrequent acid regurgitation, frequent heart burn and infrequent heart burn but we did not find any significant correlation. CONCLUSIONs: Our data show that drinking or making food using water with nitrate level more than 100mg/dl regularly correlates with experiencing frequent (at least weekly) acid regurgitation. If this holds true in direct studies and considering the potential pathophysiologic roles of nitrate metabolites, we may be able to explain several unanswered questions regarding pathogenesis and epidemiology of GERD (a possible Nitrate Theory for GERD)
Data presented as median (25th-75th perc). Post-hoc analysis a HV vs. SSBE p<0.05, b HV vs. LSBE p<0.05, c HV vs. EE p<0.05, d EE vs. SSBE p<0.05, e EE vs. LSBE p<0.05, f SSBE vs. LSBE p<0.05 T1696 Reflux Patterns Differ Among Patients With Non-Erosive Reflux Disease (NERD), Hypersensitive Esophagus (HE) and Functional Heartburn (FH) Edoardo Savarino, Patrizia Zentilin, Elisa Marabotto, Radu Tutuian, Daniel Pohl, Giorgio Sammito, Lorenzo Gemignani, Vincenzo Savarino Introduction: Non-erosive reflux disease (NERD) is an heterogeneous condition including patients with different pathophysiological characteristics. There are limited data on reflux patterns in them. Aim: To compare reflux patterns in NERD patients subclassified by impedance-pH monitoring (MII-pH). Methods: Patients with typical reflux symptoms and normal endoscopy underwent MII-pH off-PPI therapy. PPI therapy was discontinued >30 days prior to testing. Forty-eight healthy volunteers (27F; mean age 42yrs; HV) served as controls. Esophageal acid exposure time (AET), characteristics of reflux episodes (acid/ nonacid), mean acid clearance time (MACT), median bolus clearance time (MBCT), proximal migration of refluxate and symptom association probability (SAP) were measured. Results: Of 251 NERD patients (118M; mean age 47yrs), 92 (37%) were pH-POS/SAP+, 10 (4%) pH-POS/SAP-, 86 (34%) were pH-NEG/SAP+ (Hypersensitive Esophagus) and 63 (25%) were pH-NEG/SAP- (Functional Heartburn). The total and acid reflux episodes were significantly higher (p<0.01) in pH-POS/SAP+ (60[45-94] and 44[33-59]) and pH-POS/SAP- (58[5487] and 44[42-65]) compared to pH-NEG/SAP+ (43[26-64] and 25[11-37]), pH-NEG/SAP(30[17-43] and 16[8-27]) and HV (32[19-43] and 17[8-31]). Patients pH-NEG/SAP+ had a significantly increased number of weakly acidic reflux episodes compared to pH-POS/ SAP+, pH-POS/SAP-, pH-NEG/SAP- and HV (27[15-41] vs. 19[13-26] vs. 20[13-57] vs. 22[15-28] vs. 18[14-26];p<0.01). Differences in AET, acid and bolus clearance times and percentage of proximal reflux episodesare shown in the Table. Conclusion: Patients with abnormal AET have the most severe degree of reflux disease. In patients with normal AET and SAP+, an increased number of weakly acidic reflux and a high rate of proximal reflux are the main discriminant features. Finally, the large overlap between FH and HV supports the functional origin of FH.
T1694 Characteristics of Asymptomatic Gastroesophageal Reflux Disease (GERD) and Association With Lifestyle Factors - Asymptomatic GERD vs. Non-Erosive Reflux Disease (NERD) Shotaro Enomoto, Masashi Oka, Chizu Mukoubayashi, Mika Watanabe, Hisanobu Deguchi, Kazuki Ueda, Izumi Inoue, Takao Maekita, Mikitaka Iguchi, Kimihiko Yanaoka, Hideyuki Tamai, Osamu Mohara, Masao Ichinose Background: Acid reflux symptoms such as heartburn are considered important in the diagnosis of gastroesophageal reflux disease (GERD), and non-erosive reflux disease (NERD) has thus been attracting attention. However, unlike NERD, so-called asymptomatic GERD (A-GERD) showing reflux esophagitis (RE) without acid reflux symptoms is also observed. Few studies have examined the pathological characteristics of A-GERD. Methods: We compared pathological characteristics and lifestyle habits between patients with A-GERD and NERD. Between January 2006 and March 2008, upper gastrointestinal endoscopic examination, blood analysis (including examination of serum pepsinogen (PG) level and Helicobacter pylori antibody titer), evaluation using the frequency scale of symptoms of GERD (FSSG), and a questionnaire regarding lifestyle habits were performed for 3,898 patients. A-GERD was defined as the presence of RE (Los Angeles classification grade A-D) and an acid reflux symptom score of 0. NERD was defined as the absence of RE and an acid reflux symptom score ≧1. Results: Of all subjects, 44% were classified as the NERD group and 4% as the A-GERD group. In the A-GERD group, RE grade was A in 69%, B in 29%, and C in 2%. H. pylori-positive and serum PG test-positive rates were significantly lower in the A-GERD group (P<0.001 and P<0.05, respectively). Dyspepsia symptom score was significantly lower in the A-GERD group (P<0.001). The percentage of smokers was significantly higher in the A-GERD group (P<0.001), but that of drinkers did not differ significantly between groups.
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Study of Relationship Between Acid Pocket and Gastroesophageal Reflux Disease Liu Fei, Bai Lu, Hu Y. Dong Objective: This study investigated acid pocket in healthy subjects, reflux esophagitis (RE) patients and non-erosive reflux disease (NERD) patients to assess the possible role acid pocket (AP) played in pathogenesis of gastroesophageal reflux disease (GERD). Methods: Fifty GERD patients and nineteen normal subjects were involved. The patients were divided into two groups depending on whether having esophageal mucosa damage. Subjects had esophageal manometry undertaken to locate lower esophageal sphincter (LES). Then a singlechannel PH electrode was position 1 cm below the distal border of the LES. The base pH was detected for half an hour. After that, the subjects were given a standard meal. Two hours later, the electrode was moved to 5 cm above the proximal border of the LES for twenty-four hours to monitor the esophageal acid reflux. Result: AP was found in thirtyfour patients(68.00%)and eleven controls(57.90%). RE patients had higher incidence rate (14/19,73.7%) of AP than NERD patients(20/31,64.52%). But the proportion had no statistical significance. AP occurred more early after meals in GERD patients compared with controls(17.38,12.00(4.75-24.75) vs. 33.09,32.00(12-49)p=0.039) (min). RE patients had lower pH of AP than controls (1.84±0.51 vs. 2.33±0.49 p=0.035) and NERD patients (1.84±0.51 vs. 2.30±0.62 p=0.023). Results of the ambulatory pH monitoring suggested the emergence time of AP was earlier in positive esophageal acid reflux patients than negative ones (11.71,10(3-21)vs. 25.52,18(8-37)p=0.048) (min), and the pH of positive ones was lower than negative (1.87±0.60 vs. 2.30±0.56 p=0.023), but the persistence time of AP has no statistical difference. Conclusion :AP is a normal buffer area in gastroesophageal junction after meal. The earlier emergence time of AP is relevant to GERD. There is a link between esophageal mucosa injury of RE and lower pH of AP. Earlier occurrence and lower pH of AP contribute to abnormal esophageal acid reflux of GERD patients.
Data are presented as median (25th-75th percentile). Post-hoc analysis a pH-POS/SAP+ vs. pH-POS/SAP- p<0.05, b pH-POS/SAP+ vs. pH-NEG/SAP+ p<0.05, c pH-POS/SAP+ vs. pHNEG/SAP- p<0.05, d pH-POS/SAP+ vs. HV p<0.05, e pH-POS/SAP- vs. pH-NEG/SAP+ p<0.05, f pH-POS/SAP- vs. pH-NEG/SAP- p<0.05, g pH-POS/SAP- vs. HV p<0.05, h pHNEG/SAP+ vs. pH-NEG/SAP- p<0.05, i pH-NEG/SAP+ vs. HV p<0.05 T1697 The Incidence of Gastroesophageal Reflux Disease and Barrett's Esophagus is Increased in Patients With Cervical Inlet Patch Andras I. Rosztoczy, Sonja Dulic, István Németh, Ferenc Izbeki, Richárd Róka, Krisztina Gecse, Tibor Gyökeres, Ildiko Kiss, László Tiszlavicz, Tibor Wittmann Although the pathogenesis of cervical inlet patch (CIP) - heterotopic gastric mucosal island in the proximal esophagus - is not fully understood, most authors consider it as a congenital abnormality, whereas others surmise it to be related to proximal gastroesophageal reflux. Therefore we aimed to evaluate the esophageal function and the prevalence of gastroesophageal reflux disease (GERD) and Barrett esophagus in patients with CIP. Patients, Methods: 54 consecutive patients (M/F 28/26, mean age: 46.9ys.) with endoscopic and histological evidence of CIP were prospectively studied. Esophageal symptom analysis, 24-hour simultaneous Bilitec and 2ch pH-monitoring, esophageal manometry, and video barium esophagography (VBE) were carried out in 51/54 patients. Functional tests could not be done in 2 men with severe peptic esophageal stricture, in one man with malignant pancreatic neoplasm and in a woman with Zenker's diverticulum. Results: The histological evaluation showed cardia and/or oxynthic mucosa in all patients, with Schaffer's glands in 6, pancreatic acinar metaplasia in 7 cases and specialized intestinal metaplasia (SIM) in 2 cases. Low grade dysplasia was present in 1 patient. Erosive esophagitis was present in 26 patients. At the gastroesophageal junction columnar cardia/oxynthic metaplasia was found in 16, and specialized intestinal metaplasia in 8 patient. Typical reflux symptoms were commonly observed (27/54). The 24-hour 2ch pH-monitoring detected abnormal acid reflux in the distal esophagus in 24, while proximal reflux was established in 15 cases. Acid secretion in the mucosal patches were detected in 2 cases. Biliary reflux was occurred in 25 patients. Esophageal manometry showed low distal esophageal sphincter pressure in 20, prolonged relaxation in 25, and esophageal body dysmotility in 25 cases. On VBE signs of reflux were observed in 15 patients, 8 of them were proximal. Conclusions: The low prevalence of proximal gastroesophageal reflux may support the hypothesis that CIP is rather a congenital, than an acquired abnormality. On the other hand, it is more likely for these patients to have GERD and Barrett's esophagus, than it is expected on the basis of epidemiologic studies. Further studies needed to evaluate the clinical significance of SIM in the CIP.
T1700 Dyslipidemia is a Risk Factor for NERD, but Not for Functional Heartburn Juntaro Matsuzaki, Hidekazu Suzuki, Eisuke Iwasaki, Yoshinori Sugino, Hirokazu Yokoyama, Toshifumi Hibi Background: Metabolic syndrome and obesity are known risk factors for gastroesophageal reflux disease (GERD), especially for erosive esophagitis. Although non-erosive reflux disease (NERD) is probably associated with obesity and metabolic syndrome, there is little direct evidence to support this claim. Methods: Three hundred twenty one workers at Keio University who underwent a general health examination including an upper gastrointestinal barium radiogram for gastric cancer screening between September 2006 and August 2007 were enrolled. Subjects with histories of recent drug use and subjects with structural abnormalities of the esophagus, stomach, or duodenum were excluded. A reflux symptom questionnaire consisting of the Carlsson-Dent self-administered questionnaire (QUEST) and a frequency scale for the symptoms of gastroesophageal reflux disease (FSSG) were administered, and several parameters of metabolic syndrome were obtained. The severity of mechanical gastroesophageal reflux (GER) was evaluated using the X-ray videoesophagographic severity score for gastroesophageal reflux (XRSS) (Iwasaki et al, J. Gastroenterol. Hepatol. 23(S2):21621, 2008). Results: 283 subjects (243 male and 40 female; mean age 49.8 ± 6.9 years) with no evidence of erosive esophagitis were included in the analysis. The severity of GER (by XRSS) was worse in males; conversely, the severity of reflux symptom was worse in females. Although the severity of GER was significantly associated with age and with serum levels of triglycerides in males (β=.158, p=.01), and serum levels of low-density lipoprotein cholesterols in females (β=.335, p=.03), the severity of the reflux symptoms was not associated with any metabolic parameters. Males were significantly less likely than females to have reflux symptoms and no GER (‘presumed' functional heartburn group) (p<.05). In males with both reflux symptoms and GER (‘presumed' NERD group), the severity of GER was associated with elevated serum levels of triglyceride (NERD 143.2±104.3 mg/dL; control 109.3±60.6 mg/dL; p=.05). Body mass index and waist circumference were not associated with the presence of NERD, since obese subjects rarely included in the present study. Conclusion: Mechanical GER was more prevalent in males, whereas functional heartburn was more common in females. NERD, but not functional heartburn, was associated with dyslipidemia.
T1698 Childhood Obesity and Gastroesophageal Reflux Disease: A New Epidemic? Robert R. Schade, Marek Lukacik, Catherine L. Davis Gastroesophageal reflux disease is a common disorder in the primary care setting and is an important source of healthcare expense. Previously a large cross-sectional survey indicated that 3-5% of children suffer from heartburn symptoms [1]. GERD in adults has been linked to obesity, and weight loss has been advocated as a treatment for more than a decade. Little is known however about any correlation between childhood obesity and GERD. With obesity becoming more prevalent in the pediatric population we might anticipate that the incidence of GERD in this group may also increase. Methods: Overweight and obese children who were enrolled in a larger study to evaluate the value of exercise for their condition were asked at the beginning of the trial to voluntarily participate in a survey exploring symptoms of GERD. In addition they were also asked to quantify various quality-of-life aspects related to reflux including issues of allergy-like symptoms, sinus pain, and ear pain as well as symptoms of nausea and substernal burning. This survey was approved by the institutional review board and utilized previously validated test questions for GERD evaluation, along with a pain rating scale. Results: 75 subjects participated in the survey thus far. The mean age of the subjects was 9.6 ± 0.86 years and ranged from 8.0-11.6 years. There were 30 boys and 45 girls with a mean weight of 148 ± 3.94 pounds (53.7 kg), the mean body mass index was 26. Fifteen subjects had a body mass index from the 80th percentile to the 94.9th percentile and 60 participants had a body mass index that met or exceeded the 95th percentile. 25% of the subjects complained of GERD symptoms. Symptoms of nausea were present in 19.7% and a substernal burning sensation was reported by 25% of the subjects, a sour taste by 25%, and upper abdominal pain and discomfort in 17.1%. None of the patients were on acid suppressive medication. There was no statistically significant difference in symptoms between the overweight children and those who were classified as obese. Conclusion: In this interim analysis of a cohort of overweight and obese children, GERD is highly prevalent, correlating with studies reported in adults. Obesity or overweight should be considered a risk factor for GERD in the pediatric population as well. As obesity becomes more prevalent in this young group, symptomatic GERD may increasingly impact healthcare spending and chronic GERD may have ramifications on the long-term health of obese children. 1.Nelson SP, etal. Prevalence of symptoms of gastroesophageal reflux during childhood: A pediatric based survey. Arch Pediatr Adolesc Med 2000: 154; 150-154.
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T1701 Is Nonacid Reflux Increased in Cholecystectomized Patients With Typical Reflux Symptoms? A Study Using Impedance-pH Monitoring Edoardo Savarino, Giorgio Sammito, Lorenzo Gemignani, Elisa Marabotto, Patrizia Zentilin, Vincenzo Savarino Introduction: Previous studies demonstrated that patients with colecystectomy have a reduced circadian gastric acidity and an increased Duodeno-Gastro-Esophageal Reflux using pH-metry and Bilitec devices. Still, limited data are present on the frequency of nonacid reflux in patients with colecystectomy. Aim: To evaluate impedance-pH patterns in gastroesophageal reflux disease patients with and without cholecystectomy. Methods: We evaluated 164 consecutive patients with typical reflux symptoms (82F, median age 55) using impedance-pH and upper endoscopy. We divided them in cholecystectomized (CCE-group: n= 62) and non-cholecystectomized (nCCE-group: n=62) patients. Forty-eight healthy volunteers (27F, median age 42) served as controls. PPI therapy was discontinued >30 days prior to testing. We evaluated distal (5cm above LES) esophageal acid exposure time (AET, % time pH<4), number and characteristics of reflux episodes (acid, nonacid) and proximal (15 cm above LES) migration of the refluxate. Results: Data are shown in the Table. Out of 62 nCCE patients, 30 had an abnormal AET, while among CCE patients 21 (48% vs. 34%, p=ns) had an abnormal AET. Patients without cholecystectomy had higher AET and number of acid reflux events compared to patients with cholecystectomy and HV (p<0.05). CCE patients had an increased number of nonacid reflux compared to nCCE patients and HV (p<0.05). The proportion of reflux episodes that was acidic and nonacidic in patients
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The Association Between Acid Reflux and Cough in Patients With Cystic Fibrosis is Not Dependent on the Type of Acid Reflux Frederick W. Woodley, John Hayes, Alpa Patel, Karen McCoy, Hayat Mousa Background: Association of acid gastroesophageal reflux (AGER) with cough has been demonstrated in adult patients with cystic fibrosis (CF). We previously showed that use of combined esophageal pH monitoring and multichannel intraluminal impedance (EPM/MII) reveals 4 distinct types of AGER episodes; classic two-phase, single-phase, pH only, and re-reflux AGER episodes. Specific Aim: To investigate the question whether specific types of AGER might predict coughing in CF patients. Methods: 24-hr EPM/MII reports from 27 CF patients (no anti-reflux meds and no fundoplication) were reviewed. Patients for whom analysis demonstrated an association of AGER with cough (co-occurrence within 5-min windows with SAP ≥95%) were analyzed. Total AGER episodes within this subset of patients were divided into AGER types and analyses were repeated. Results: 1) Association of AGER with coughing was detected in 9 of 27 CF patients (5M/4F, median age 18.5yrs, range 6.148.5yrs). 2) Of those selected patients, the mean number of AGER was 133 (Range 69 to 231) in which 28% were two phase, 13% were single phase, 53% were pH only events, and 6% were re-reflux (Friedman p<0.001). 3) The mean percent events associated with cough were 29.4% for two phase, 33.7% for single phase, 24.9% for pH only events, and 32.9% for re-reflux (Friedman p=.31). Summary and Conclusions: While two-phase and pH only episodes occurred more often than single-phase and re-reflux episodes, specific types of AGER did not predict cough. We conclude that all AGER types should be considered when assessing the association of AGER with cough in CF patients.
T1695 Reflux Patterns in Patients With Short and Long Segment Barrett's Esophagus, Erosive Esophagitis and Controls: A Study Using Impedance-pH Monitoring Edoardo Savarino, Patrizia Zentilin, Daniel Pohl, Elisa Marabotto, Giorgio Sammito, Lorenzo Gemignani, Radu Tutuian, Vincenzo Savarino Introduction: Several studies documented higher esophageal acid exposure in Barrett's esophagus (BE) than in other forms of GERD. Differences in composition, migration and clearance of reflux events are currently underinvestigated. Aim: To compare reflux patterns in patients with BE, erosive esophagitis (EE) and controls using 24-hour MII-pH. Methods: One-hundred consecutive patients with BE, 50 with EE and 48 controls underwent MIIpH off-therapy. We quantified distal esophageal acid exposure time (AET), number of reflux episodes (acid, nonacid), mean acid clearance time (MACT), median bolus clearance time (MBCT) and proximal (15 cm above LES) migration of the refluxate. Results: The degree of gastroesophageal reflux increased with respect to the severity of mucosal damage, as shown in the Table. Twenty-five patients (100%) with LSBE, 66 (88%) with SSBE and 40 (80%) with EE had abnormal AET. Total and acid reflux episodes gradually increased from controls to EE, SSBE and LSBE (p<0.01). Weakly acidic reflux events were significantly higher in LSBE and SSBE than in EE and controls (p<0.05). Re-reflux episodes were more common in LSBE (73%) compared to SSBE (63%), EE (43%) and controls (7%). Conclusion: Refluxers with metaplastic epithelium have longer esophageal refluxate (both acid and weakly acidic) exposure time, higher number of total reflux episodes, increased number of re-reflux events and prolonged acid and volume clearance times. Impedance data suggest that the severity of mucosal damage is strictly related to the degree of reflux disease and therefore to the severity of antireflux barrier incompetence. The contribution of weakly acidic reflux to the pathogenesis of BE warrants further investigations.
T1693 High Nitrate Intake May Be Related to GERD: An Ecologic Study Siavosh Nasseri-Moghaddam, Azadeh Mofid, Hadi Razjouyan, Mehdi Nouraie, Reza Malekzadeh INTRODUCTION: GERD is a common disease in Tehran (21.2% of the population). Nitrate content of drinking water has been reported to be higher than recommended values in some parts of Tehran. This motivated us to assess the correlation of nitrate content of drinking water with GERD prevalence in a population-based study. AIMS & METHODS: In this study, a random clustered sample of the city of Tehran permanent households was selected from the latest postcodes. Data were collected by direct interview for each person aged 1865 yr. Frequent GERD was defined as existence of at least weekly episodes of heartburn and/or acid regurgitation during the last 12 months. Data about nitrate content of drinking water in different areas of Tehran was obtained from the regional water organization of Tehran. Odds ratios and 95% CIs were calculated and a multivariable model analyzed. RESULTS: Interview was performed with 2,561 eligible subjects (42.3% men, response rate: 84.8%) and 2,058 (80.4%) were included in the final analysis. The prevalence of frequent acid regurgitation, infrequent acid regurgitation, frequent heart burn and infrequent heart burn were 15.7%, 25.5%, 10.7% and 11.8% respectively. Nitrate levels in drinking water were as follow: 20.0% areas with nitrate level under 50mg/dl, 62.1% areas with nitrate level between 50l and 75mg/dl, 15.0% areas with nitrate level of 75-100mg/dl, and 2.9% areas with nitrate level more than 100mg/dl. Individuals living in areas with drinking water containing more than 100mg/dl nitrate were more likely to experience frequent acid regurgitation than people who lived in areas with water containing less than 100mg/dl nitrate (29.2% vs. 15.3%, OR 2.88, 95% CI: 1.24-6.68, p value: 0.01). After adjustment for sex, age, education level, smoking, BMI, NSAID consumption, positive family history for GERD and positive spouse history for GERD, the correlation remained significant. We repeated this analysis for infrequent acid regurgitation, frequent heart burn and infrequent heart burn but we did not find any significant correlation. CONCLUSIONs: Our data show that drinking or making food using water with nitrate level more than 100mg/dl regularly correlates with experiencing frequent (at least weekly) acid regurgitation. If this holds true in direct studies and considering the potential pathophysiologic roles of nitrate metabolites, we may be able to explain several unanswered questions regarding pathogenesis and epidemiology of GERD (a possible Nitrate Theory for GERD)
Data presented as median (25th-75th perc). Post-hoc analysis a HV vs. SSBE p<0.05, b HV vs. LSBE p<0.05, c HV vs. EE p<0.05, d EE vs. SSBE p<0.05, e EE vs. LSBE p<0.05, f SSBE vs. LSBE p<0.05 T1696 Reflux Patterns Differ Among Patients With Non-Erosive Reflux Disease (NERD), Hypersensitive Esophagus (HE) and Functional Heartburn (FH) Edoardo Savarino, Patrizia Zentilin, Elisa Marabotto, Radu Tutuian, Daniel Pohl, Giorgio Sammito, Lorenzo Gemignani, Vincenzo Savarino Introduction: Non-erosive reflux disease (NERD) is an heterogeneous condition including patients with different pathophysiological characteristics. There are limited data on reflux patterns in them. Aim: To compare reflux patterns in NERD patients subclassified by impedance-pH monitoring (MII-pH). Methods: Patients with typical reflux symptoms and normal endoscopy underwent MII-pH off-PPI therapy. PPI therapy was discontinued >30 days prior to testing. Forty-eight healthy volunteers (27F; mean age 42yrs; HV) served as controls. Esophageal acid exposure time (AET), characteristics of reflux episodes (acid/ nonacid), mean acid clearance time (MACT), median bolus clearance time (MBCT), proximal migration of refluxate and symptom association probability (SAP) were measured. Results: Of 251 NERD patients (118M; mean age 47yrs), 92 (37%) were pH-POS/SAP+, 10 (4%) pH-POS/SAP-, 86 (34%) were pH-NEG/SAP+ (Hypersensitive Esophagus) and 63 (25%) were pH-NEG/SAP- (Functional Heartburn). The total and acid reflux episodes were significantly higher (p<0.01) in pH-POS/SAP+ (60[45-94] and 44[33-59]) and pH-POS/SAP- (58[5487] and 44[42-65]) compared to pH-NEG/SAP+ (43[26-64] and 25[11-37]), pH-NEG/SAP(30[17-43] and 16[8-27]) and HV (32[19-43] and 17[8-31]). Patients pH-NEG/SAP+ had a significantly increased number of weakly acidic reflux episodes compared to pH-POS/ SAP+, pH-POS/SAP-, pH-NEG/SAP- and HV (27[15-41] vs. 19[13-26] vs. 20[13-57] vs. 22[15-28] vs. 18[14-26];p<0.01). Differences in AET, acid and bolus clearance times and percentage of proximal reflux episodesare shown in the Table. Conclusion: Patients with abnormal AET have the most severe degree of reflux disease. In patients with normal AET and SAP+, an increased number of weakly acidic reflux and a high rate of proximal reflux are the main discriminant features. Finally, the large overlap between FH and HV supports the functional origin of FH.
T1694 Characteristics of Asymptomatic Gastroesophageal Reflux Disease (GERD) and Association With Lifestyle Factors - Asymptomatic GERD vs. Non-Erosive Reflux Disease (NERD) Shotaro Enomoto, Masashi Oka, Chizu Mukoubayashi, Mika Watanabe, Hisanobu Deguchi, Kazuki Ueda, Izumi Inoue, Takao Maekita, Mikitaka Iguchi, Kimihiko Yanaoka, Hideyuki Tamai, Osamu Mohara, Masao Ichinose Background: Acid reflux symptoms such as heartburn are considered important in the diagnosis of gastroesophageal reflux disease (GERD), and non-erosive reflux disease (NERD) has thus been attracting attention. However, unlike NERD, so-called asymptomatic GERD (A-GERD) showing reflux esophagitis (RE) without acid reflux symptoms is also observed. Few studies have examined the pathological characteristics of A-GERD. Methods: We compared pathological characteristics and lifestyle habits between patients with A-GERD and NERD. Between January 2006 and March 2008, upper gastrointestinal endoscopic examination, blood analysis (including examination of serum pepsinogen (PG) level and Helicobacter pylori antibody titer), evaluation using the frequency scale of symptoms of GERD (FSSG), and a questionnaire regarding lifestyle habits were performed for 3,898 patients. A-GERD was defined as the presence of RE (Los Angeles classification grade A-D) and an acid reflux symptom score of 0. NERD was defined as the absence of RE and an acid reflux symptom score ≧1. Results: Of all subjects, 44% were classified as the NERD group and 4% as the A-GERD group. In the A-GERD group, RE grade was A in 69%, B in 29%, and C in 2%. H. pylori-positive and serum PG test-positive rates were significantly lower in the A-GERD group (P<0.001 and P<0.05, respectively). Dyspepsia symptom score was significantly lower in the A-GERD group (P<0.001). The percentage of smokers was significantly higher in the A-GERD group (P<0.001), but that of drinkers did not differ significantly between groups.
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Study of Relationship Between Acid Pocket and Gastroesophageal Reflux Disease Liu Fei, Bai Lu, Hu Y. Dong Objective: This study investigated acid pocket in healthy subjects, reflux esophagitis (RE) patients and non-erosive reflux disease (NERD) patients to assess the possible role acid pocket (AP) played in pathogenesis of gastroesophageal reflux disease (GERD). Methods: Fifty GERD patients and nineteen normal subjects were involved. The patients were divided into two groups depending on whether having esophageal mucosa damage. Subjects had esophageal manometry undertaken to locate lower esophageal sphincter (LES). Then a singlechannel PH electrode was position 1 cm below the distal border of the LES. The base pH was detected for half an hour. After that, the subjects were given a standard meal. Two hours later, the electrode was moved to 5 cm above the proximal border of the LES for twenty-four hours to monitor the esophageal acid reflux. Result: AP was found in thirtyfour patients(68.00%)and eleven controls(57.90%). RE patients had higher incidence rate (14/19,73.7%) of AP than NERD patients(20/31,64.52%). But the proportion had no statistical significance. AP occurred more early after meals in GERD patients compared with controls(17.38,12.00(4.75-24.75) vs. 33.09,32.00(12-49)p=0.039) (min). RE patients had lower pH of AP than controls (1.84±0.51 vs. 2.33±0.49 p=0.035) and NERD patients (1.84±0.51 vs. 2.30±0.62 p=0.023). Results of the ambulatory pH monitoring suggested the emergence time of AP was earlier in positive esophageal acid reflux patients than negative ones (11.71,10(3-21)vs. 25.52,18(8-37)p=0.048) (min), and the pH of positive ones was lower than negative (1.87±0.60 vs. 2.30±0.56 p=0.023), but the persistence time of AP has no statistical difference. Conclusion :AP is a normal buffer area in gastroesophageal junction after meal. The earlier emergence time of AP is relevant to GERD. There is a link between esophageal mucosa injury of RE and lower pH of AP. Earlier occurrence and lower pH of AP contribute to abnormal esophageal acid reflux of GERD patients.
Data are presented as median (25th-75th percentile). Post-hoc analysis a pH-POS/SAP+ vs. pH-POS/SAP- p<0.05, b pH-POS/SAP+ vs. pH-NEG/SAP+ p<0.05, c pH-POS/SAP+ vs. pHNEG/SAP- p<0.05, d pH-POS/SAP+ vs. HV p<0.05, e pH-POS/SAP- vs. pH-NEG/SAP+ p<0.05, f pH-POS/SAP- vs. pH-NEG/SAP- p<0.05, g pH-POS/SAP- vs. HV p<0.05, h pHNEG/SAP+ vs. pH-NEG/SAP- p<0.05, i pH-NEG/SAP+ vs. HV p<0.05 T1697 The Incidence of Gastroesophageal Reflux Disease and Barrett's Esophagus is Increased in Patients With Cervical Inlet Patch Andras I. Rosztoczy, Sonja Dulic, István Németh, Ferenc Izbeki, Richárd Róka, Krisztina Gecse, Tibor Gyökeres, Ildiko Kiss, László Tiszlavicz, Tibor Wittmann Although the pathogenesis of cervical inlet patch (CIP) - heterotopic gastric mucosal island in the proximal esophagus - is not fully understood, most authors consider it as a congenital abnormality, whereas others surmise it to be related to proximal gastroesophageal reflux. Therefore we aimed to evaluate the esophageal function and the prevalence of gastroesophageal reflux disease (GERD) and Barrett esophagus in patients with CIP. Patients, Methods: 54 consecutive patients (M/F 28/26, mean age: 46.9ys.) with endoscopic and histological evidence of CIP were prospectively studied. Esophageal symptom analysis, 24-hour simultaneous Bilitec and 2ch pH-monitoring, esophageal manometry, and video barium esophagography (VBE) were carried out in 51/54 patients. Functional tests could not be done in 2 men with severe peptic esophageal stricture, in one man with malignant pancreatic neoplasm and in a woman with Zenker's diverticulum. Results: The histological evaluation showed cardia and/or oxynthic mucosa in all patients, with Schaffer's glands in 6, pancreatic acinar metaplasia in 7 cases and specialized intestinal metaplasia (SIM) in 2 cases. Low grade dysplasia was present in 1 patient. Erosive esophagitis was present in 26 patients. At the gastroesophageal junction columnar cardia/oxynthic metaplasia was found in 16, and specialized intestinal metaplasia in 8 patient. Typical reflux symptoms were commonly observed (27/54). The 24-hour 2ch pH-monitoring detected abnormal acid reflux in the distal esophagus in 24, while proximal reflux was established in 15 cases. Acid secretion in the mucosal patches were detected in 2 cases. Biliary reflux was occurred in 25 patients. Esophageal manometry showed low distal esophageal sphincter pressure in 20, prolonged relaxation in 25, and esophageal body dysmotility in 25 cases. On VBE signs of reflux were observed in 15 patients, 8 of them were proximal. Conclusions: The low prevalence of proximal gastroesophageal reflux may support the hypothesis that CIP is rather a congenital, than an acquired abnormality. On the other hand, it is more likely for these patients to have GERD and Barrett's esophagus, than it is expected on the basis of epidemiologic studies. Further studies needed to evaluate the clinical significance of SIM in the CIP.
T1700 Dyslipidemia is a Risk Factor for NERD, but Not for Functional Heartburn Juntaro Matsuzaki, Hidekazu Suzuki, Eisuke Iwasaki, Yoshinori Sugino, Hirokazu Yokoyama, Toshifumi Hibi Background: Metabolic syndrome and obesity are known risk factors for gastroesophageal reflux disease (GERD), especially for erosive esophagitis. Although non-erosive reflux disease (NERD) is probably associated with obesity and metabolic syndrome, there is little direct evidence to support this claim. Methods: Three hundred twenty one workers at Keio University who underwent a general health examination including an upper gastrointestinal barium radiogram for gastric cancer screening between September 2006 and August 2007 were enrolled. Subjects with histories of recent drug use and subjects with structural abnormalities of the esophagus, stomach, or duodenum were excluded. A reflux symptom questionnaire consisting of the Carlsson-Dent self-administered questionnaire (QUEST) and a frequency scale for the symptoms of gastroesophageal reflux disease (FSSG) were administered, and several parameters of metabolic syndrome were obtained. The severity of mechanical gastroesophageal reflux (GER) was evaluated using the X-ray videoesophagographic severity score for gastroesophageal reflux (XRSS) (Iwasaki et al, J. Gastroenterol. Hepatol. 23(S2):21621, 2008). Results: 283 subjects (243 male and 40 female; mean age 49.8 ± 6.9 years) with no evidence of erosive esophagitis were included in the analysis. The severity of GER (by XRSS) was worse in males; conversely, the severity of reflux symptom was worse in females. Although the severity of GER was significantly associated with age and with serum levels of triglycerides in males (β=.158, p=.01), and serum levels of low-density lipoprotein cholesterols in females (β=.335, p=.03), the severity of the reflux symptoms was not associated with any metabolic parameters. Males were significantly less likely than females to have reflux symptoms and no GER (‘presumed' functional heartburn group) (p<.05). In males with both reflux symptoms and GER (‘presumed' NERD group), the severity of GER was associated with elevated serum levels of triglyceride (NERD 143.2±104.3 mg/dL; control 109.3±60.6 mg/dL; p=.05). Body mass index and waist circumference were not associated with the presence of NERD, since obese subjects rarely included in the present study. Conclusion: Mechanical GER was more prevalent in males, whereas functional heartburn was more common in females. NERD, but not functional heartburn, was associated with dyslipidemia.
T1698 Childhood Obesity and Gastroesophageal Reflux Disease: A New Epidemic? Robert R. Schade, Marek Lukacik, Catherine L. Davis Gastroesophageal reflux disease is a common disorder in the primary care setting and is an important source of healthcare expense. Previously a large cross-sectional survey indicated that 3-5% of children suffer from heartburn symptoms [1]. GERD in adults has been linked to obesity, and weight loss has been advocated as a treatment for more than a decade. Little is known however about any correlation between childhood obesity and GERD. With obesity becoming more prevalent in the pediatric population we might anticipate that the incidence of GERD in this group may also increase. Methods: Overweight and obese children who were enrolled in a larger study to evaluate the value of exercise for their condition were asked at the beginning of the trial to voluntarily participate in a survey exploring symptoms of GERD. In addition they were also asked to quantify various quality-of-life aspects related to reflux including issues of allergy-like symptoms, sinus pain, and ear pain as well as symptoms of nausea and substernal burning. This survey was approved by the institutional review board and utilized previously validated test questions for GERD evaluation, along with a pain rating scale. Results: 75 subjects participated in the survey thus far. The mean age of the subjects was 9.6 ± 0.86 years and ranged from 8.0-11.6 years. There were 30 boys and 45 girls with a mean weight of 148 ± 3.94 pounds (53.7 kg), the mean body mass index was 26. Fifteen subjects had a body mass index from the 80th percentile to the 94.9th percentile and 60 participants had a body mass index that met or exceeded the 95th percentile. 25% of the subjects complained of GERD symptoms. Symptoms of nausea were present in 19.7% and a substernal burning sensation was reported by 25% of the subjects, a sour taste by 25%, and upper abdominal pain and discomfort in 17.1%. None of the patients were on acid suppressive medication. There was no statistically significant difference in symptoms between the overweight children and those who were classified as obese. Conclusion: In this interim analysis of a cohort of overweight and obese children, GERD is highly prevalent, correlating with studies reported in adults. Obesity or overweight should be considered a risk factor for GERD in the pediatric population as well. As obesity becomes more prevalent in this young group, symptomatic GERD may increasingly impact healthcare spending and chronic GERD may have ramifications on the long-term health of obese children. 1.Nelson SP, etal. Prevalence of symptoms of gastroesophageal reflux during childhood: A pediatric based survey. Arch Pediatr Adolesc Med 2000: 154; 150-154.
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T1701 Is Nonacid Reflux Increased in Cholecystectomized Patients With Typical Reflux Symptoms? A Study Using Impedance-pH Monitoring Edoardo Savarino, Giorgio Sammito, Lorenzo Gemignani, Elisa Marabotto, Patrizia Zentilin, Vincenzo Savarino Introduction: Previous studies demonstrated that patients with colecystectomy have a reduced circadian gastric acidity and an increased Duodeno-Gastro-Esophageal Reflux using pH-metry and Bilitec devices. Still, limited data are present on the frequency of nonacid reflux in patients with colecystectomy. Aim: To evaluate impedance-pH patterns in gastroesophageal reflux disease patients with and without cholecystectomy. Methods: We evaluated 164 consecutive patients with typical reflux symptoms (82F, median age 55) using impedance-pH and upper endoscopy. We divided them in cholecystectomized (CCE-group: n= 62) and non-cholecystectomized (nCCE-group: n=62) patients. Forty-eight healthy volunteers (27F, median age 42) served as controls. PPI therapy was discontinued >30 days prior to testing. We evaluated distal (5cm above LES) esophageal acid exposure time (AET, % time pH<4), number and characteristics of reflux episodes (acid, nonacid) and proximal (15 cm above LES) migration of the refluxate. Results: Data are shown in the Table. Out of 62 nCCE patients, 30 had an abnormal AET, while among CCE patients 21 (48% vs. 34%, p=ns) had an abnormal AET. Patients without cholecystectomy had higher AET and number of acid reflux events compared to patients with cholecystectomy and HV (p<0.05). CCE patients had an increased number of nonacid reflux compared to nCCE patients and HV (p<0.05). The proportion of reflux episodes that was acidic and nonacidic in patients
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