Gastroesophageal Reflux Disease, An issue of Gastroenterology Clinics of North America (eBook)

Joel E Richter (Autor)

eBook Download: PDF | EPUB

2014 | 1. Auflage
201 Seiten
Elsevier Health Sciences (Verlag)
978-0-323-29029-6 (ISBN)

Infos

Gastroesophageal reflux disease and its complications effect 40 % of the US population. It is the most common reason for outpatient GI visits with treatment costs amounting to nearly $10 billion a year. Thisissue updates interested physicians on the new advance in GERD pathogenesis, diagnosis and medical/surgical treatment , especially over the last 5 years. Lots of advancements have been made in this time period and this will be a excellent reference book for the busy academic and community physician interested in GERD.

Inhalt

Front Cover 1
GASTROENTEROLOGYCLINICS OF NORTH AMERICA 2
Copyright page 
3 
Contributors 4
Consulting Editor 4
Editor 4
Authors 4
Contents 6
Forthcoming Issues 10
Forthcoming Issues 10
June 2014 10
September 2014 10
December 2014 10
Recent Issues 10
December 2013 10
September 2013 10
June 2013 10
Gastroesophageal Reflux Disease 
12 
What's New in Gastroesophageal Reflux Disease for 2014 14
Epidemiology of Gastroesophageal Reflux Disease 16
Key points 16
Introduction 16
Trends in the prevalence of GERD and incidence of its complications 16
The economic impact of GERD 19
Direct Health Care Costs 19
Ambulatory care costs 20
Inpatient care costs 20
Diagnostic procedure costs 20
Pharmaceutical costs 21
Extraesophageal reflux 21
Indirect Costs of GERD 21
Risk factors for GERD 23
Summary 25
References 25
Pathophysiology of Gastroesophageal Reflux Disease 30
Key points 30
Introduction 30
The esophagogastric junction 31
TLESRs 31
Hiatal Hernia 32
Acid Pocket 33
Positive Pressure Gradient and Obesity 34
Gastric Motility 34
Esophageal Clearance 34
Perception of reflux episodes 35
Peripheral Sensitization 35
Central Sensitization and Psychoneuroimmune Interactions 35
Esophageal injury 36
Esophageal Defense and Mucosal Changes 36
Summary 37
References 37
Symptom Predictability in Gastroesophageal Reflux Disease and Role of Proton Pump Inhibitor Test 42
Key points 42
Symptom assessment 43
Issues in GERD symptom assessment 43
Evaluation of symptoms in GERD 44
Patient-reported outcomes in GERD symptom assessment 44
Sensitivity and specificity for heartburn in diagnosing GERD 47
Estimated Range Based on Recent Reviews 47
Difficulty with using heartburn as the primary means of diagnosing GERD: common occurrence of heartburn with other symptoms 48
Sensitivity and specificity of regurgitation in diagnosing GERD 48
PPI use in GERD 48
The PPI test 49
Regurgitation and acid suppression 51
References 51
Role of Endoscopy in GERD 54
Key points 54
Introduction 54
Esophagogastroduodenoscopy or upper endoscopy 55
Confocal laser endomicroscopy and optical coherence tomography 55
Wireless capsule endoscopy 56
Gastroesophageal reflux disease 56
Esophageal dilation 57
Barrett esophagus 58
Advance imaging 59
Eosinophilic esophagitis 59
Endoscopic therapies for GERD 60
Summary 60
References 60
Barium Esophagram 62
Key points 62
Esophagram: important general elements of the examination 63
The preoperative barium esophagram 64
Initial Upright Phase 64
Semiprone or Right Anterior Oblique Phase 66
Reflux Identification Phase 69
Solid Food Ingestion Phase 70
Feline Esophagus 70
Distal Mucosal Ring (Schatzki Ring) 70
Outcome of the preoperative examination 71
Alternative diagnoses to GERD 72
Diagnosis of esophagitis and Barrett esophagus with the barium esophagram 74
The barium esophagram after antireflux procedures 75
Initial Upright Phase 75
Semiprone or Right Anterior Oblique Examination 75
Reflux Identification Examination 76
Solid Food Ingestion Examination 76
Gastric Motility Assessment 76
Normal Nissen Fundoplication 76
Normal Toupet Fundoplication 76
Collis Gastroplasty–Nissen Fundoplication 77
Abnormal or Failed Fundoplication 78
Outcome of the postoperative examination 80
Summary 81
Acknowledgments 81
References 81
Esophageal Manometry in Gastroesophageal Reflux Disease 84
Key points 84
Introduction 84
Advances in esophageal manometry 84
Pathophysiologic correlates of GERD on HRM 85
Transient Lower Esophageal Sphincter Relaxations 85
Barrier Function of the Esophagogastric Junction 87
EGJ opening with reflux events 87
Pressure inversion point and hiatus hernia 87
LES hypotension 88
Esophageal Clearance 88
Esophageal Length and Other Anatomic Considerations 92
HRM software tools and metrics 93
Clinical application of HRM metrics 94
Presurgical Assessment of Peristaltic Function 95
Provocative maneuvers 97
Summary 98
References 99
Acid and Nonacid Reflux Monitoring 104
Key points 104
Introduction 104
Indications for esophageal reflux monitoring 105
Before Antireflux Surgery 105
PPI-Refractory GERD Symptoms 105
Noncardiac Chest Pain 106
Extraesophageal GERD Symptoms 106
Assessing Effectiveness of Reflux Therapy 106
Performance of esophageal reflux monitoring 106
Sensor Placement and Positioning 108
Limitation of conventional placement location 108
Test Duration 109
Patient tolerance 109
Comparisons of Esophageal Reflux Monitoring Modalities 110
Other limitations 110
On or Off PPIs? 111
Test interpretation 112
Normal Values 113
Symptom Association Assessment 114
Summary 115
References 115
Extraesophageal Presentations of GERD 120
Key points 120
Pathophysiology, or what might be going on? 121
Diagnosis, or how might the association be established? 123
What is the Value of Laryngoscopy in Assessing Patients with Suspected EER? 123
What is the Value of Endoscopy in Assessing Patients with Suspected EER? 124
What is the Value of Esophageal Reflux Studies in Assessing Patients with Suspected EER? 125
Treatment, or how well a therapeutic trial with antireflux therapy might help? 126
Reflux Cough Syndrome 126
Reflux Asthma Syndrome 127
Reflux Laryngitis Syndrome 128
Dental Erosions (Reflux Dental Erosion Syndrome) 129
Other Suspected Extraesophageal Conditions 129
Summary and final recommendations 130
References 131
Medical Treatments of GERD 136
Key points 136
Introduction 136
A pathophysiology-based approach to the medical treatment of GERD 137
Neutralization of Gastric Contents 137
Comparative effectiveness of H2RAs versus PPIs 138
Comparative effectiveness of different PPIs 139
Comparative effectiveness of PPIs versus anti-reflux surgery 139
Potassium-competitive acid blockers 140
Augmentation of the Antireflux Barrier Function 140
GABA-B agonists 141
Metabotropic glutamate receptor-5 antagonists 141
Other TLESR inhibitors 141
Enhancement of Mucosal Defense and Repair Mechanisms 142
Prokinetics 142
Mucosal repair 142
Modulating Sensation 143
Nociceptor blockade 143
Visceral analgesia and cortical modulation 143
Summary 143
References 144
Surgical Treatment of GERD 150
Key points 150
Historical review 150
Development of laparoscopic antireflux surgery 152
Keys in patient selection 154
Predictors of success 155
Keys in operative technique 155
Endoscopic antireflux surgery 156
Future developments 158
Summary 159
References 159
Gastroesophageal Reflux Disease and the Elderly 162
Key points 162
Introduction 162
Esophageal physiology and aging 163
Structural Studies 163
Esophageal Motility Studies 163
Lower esophageal sphincter 163
Esophageal body 164
Upper esophageal sphincter dysfunction 166
Sensory Changes 166
Other Changes 166
Age and GERD prevalence 167
Clinical presentation 167
Complications 169
Treatment 170
Medical Therapy 170
Surgical Therapy 171
Summary 172
References 172
Obesity and GERD 176
Key points 176
Introduction 176
Disease Description 176
Prevalence/Incidence 176
World-wide incidence rates 177
Clinical correlation 178
Complications of GERD 178
Pathophysiology 180
Weight Loss and GERD 182
Bariatric Surgery and GERD 182
Summary 184
References 184
Index 190
A 190
B 190
C 191
D 191
E 192
F 193
G 193
H 194
I 195
J 195
L 195
M 195
N 196
O 196
P 196
Q 197
R 197
S 198
T 198
U 198
V 198
W 198

Textauszug

Epidemiology of Gastroesophageal Reflux Disease

Joel H. Rubenstein, MD, MScab∗[e-mail] and Joan W. Chen, MDb,     aVeterans Affairs Center for Clinical Management Research, Ann Arbor, MI, USA; bDivision of Gastroenterology, University of Michigan Medical School, Ann Arbor, MI, USA

∗Corresponding author. VA Ann Arbor Healthcare System, 2215 Fuller Road, Mail Stop 111-D, Ann Arbor, MI 48105.

The prevalence of gastroesophageal reflux disease (GERD) symptoms increased approximately 50% until the mid-1990s, when it plateaued. The incidence of complications related to GERD including hospitalization, esophageal strictures, esophageal adenocarcinoma, and mortality also increased during that time period, but the increase in esophageal adenocarcinoma has since slowed, and the incidence of strictures has decreased since the mid-1990s. GERD is responsible for the greatest direct costs in the United States of any gastrointestinal disease, and most of those expenditures are for pharmacotherapy. Risk factors for GERD include obesity, poor diet, lack of physical activity, consumption of tobacco and alcohol, and respiratory diseases.

Keywords

Prevalence

Incidence

Risk factors

Esophageal strictures

Esophageal neoplasms

Cost

Key points

• Frequent GERD symptoms are encountered in 20% of North Americans.

• The prevalence of GERD symptoms rose, and then plateaued in the mid-1990s.

• GERD incurs the highest annual direct costs of all digestive diseases in the United States.

• Pharmaceutical cost is responsible for most of the direct cost of GERD management.

• Risk factors for GERD include obesity, poor diet, lack of leisure physical activity, consumption of tobacco and alcohol, and respiratory disease.

Introduction

Gastroesophageal reflux disease (GERD) is a condition that develops when the reflux of gastric contents causes troublesome symptoms or complications.1 GERD is responsible for some of the most common symptoms leading to presentation for medical care. The prevalence of GERD symptoms and the incidence of some of its complications have risen strikingly over the last few decades, leading to substantial economic impact. There are several potential explanations for these rising trends.

Trends in the prevalence of GERD and incidence of its complications

Symptoms of GERD seem to be more common now than 25 years ago. In systematic reviews of population-based studies, El-Serag and colleagues2,3 found that the prevalence of at least weekly symptoms of GERD rose approximately 50% until 1995, and that the prevalence has remained relatively constant since then (Fig. 1). The weighted-mean prevalence of at least weekly GERD symptoms is greatest in North America (19.8%), lowest in East Asia (5.2%), and intermediate in Europe and the Middle East (15.2% and 14.4%, respectively) (Fig. 2).3 The rate of increase in the prevalence of symptoms seems to be similar across all geographic regions studied.3

Fig. 1 Prevalence of at least weekly heartburn and/or acid regurgitation, or heartburn, with regard to the publication date of the 17 studies included in the Poisson regression analysis. Studies are categorized by geographic region (continent). (From El-Serag HB. Time trends of gastroesophageal reflux disease: a systematic review. Clin Gastroenterol Hepatol 2007;5:21; with permission.)

Fig. 2 Global distribution of the burden of gastroesophageal reflux disease. Sample-size weighted mean estimates of the prevalence of at least weekly heartburn and/or regurgitation in each country. (From El-Serag HB, Sweet S, Winchester CC, et al. Update on the epidemiology of gastro-oesophageal reflux disease: a systematic review. Gut 2013. http://dx.doi.org/10.1136/gutjnl-2012-304269; with permission.)

The source studies for that systematic review were often limited because they did not account for the use of acid-reducing medications, which would be expected to mask GERD symptoms; because the use of such medications has increased, the true prevalence of GERD (including treated and untreated) may be greater than the estimates previously mentioned. In addition, the estimates were based primarily on studies of separate samples of populations obtained at different time points. One exception is the HUNT study, which administered surveys longitudinally to the same population over time; residents of a Norwegian county answered the questions between 1995 and 1997, and the same questions again between 2006 and 2009.4 The prevalence of at least weekly GERD symptoms increased from 12% to 17% during that time period. GERD symptoms became more common in men and women, and in all age groups.

The incidence of complications of GERD also seems to have risen, but may have plateaued or even decreased since the mid-1990s. The proportion of hospitalizations in the US Veterans Affairs health care system with a primary or secondary discharge diagnosis of GERD increased fourfold between 1970 and 1996.5 Mortality directly related to GERD is very rare, but analysis of US death certificates demonstrated an increase from 1 death per 1 million individuals per year to 2.1 per 1 million between 1979 and 1992.5 In two community hospitals, the incidence of new esophageal strictures increased from 1986 to 1993, then decreased from 1994 to 2001, coinciding with a large increase in prescriptions for proton pump inhibitors (PPIs).6 In the US Veterans Affairs health care system, the incidence of new esophageal strictures decreased 12% as a proportion of all upper endoscopies from 1998 to 2003, and the 1-year incidence rate of recurrent strictures decreased 36%.7 Similarly, within the US Medicare system, the proportion of upper endoscopies with a stricture declined 11% between 1992 and 2000, and the incidence of recurrent strictures decreased 30%, coinciding with the introduction of PPIs.8

The most feared complication of GERD is esophageal adenocarcinoma, a cancer that historically had been extremely rare. The cancer is fivefold as common in individuals with chronic GERD symptoms compared with those without GERD.9 In 1991, a seminal study by Blot and colleagues10 reported an alarming doubling of the incidence of esophageal adenocarcinoma from 1976 to 1987. The incidence of esophageal adenocarcinoma thereafter climbed to sevenfold the baseline incidence, and most recently occurs in the general US population in 2.6 per 100,000 patient-years.11 World-wide, the incidence of esophageal adenocarcinoma has risen in most industrialized countries where there is a majority white population.12,13 Despite the dramatic relative increase in the incidence of esophageal adenocarcinoma, it remains a rare disease in absolute terms. Indeed, even in men with chronic GERD symptoms, the incidence of colorectal cancer is likely threefold the incidence of esophageal adenocarcinoma, and women with GERD symptoms likely have an incidence of esophageal adenocarcinoma that is similar to the incidence of breast cancer in men.14 Furthermore, the rising incidence may be reaching a plateau, because the increase in incidence has slowed in the United States since around 1997.11,15 The plateauing of the incidence of esophageal adenocarcinoma might be in part related to the advent of PPIs.

Just as the incidence of esophageal adenocarcinoma has risen, there has been a dramatic rise in the incidence of diagnosed cases of Barrett's esophagus, the premalignant lesion associated with esophageal adenocarcinoma. For example, in a Dutch primary care database, the incidence of newly diagnosed cases of Barrett's esophagus rose from 11 per 100,000 patients in 1996 to 23 per 100,000 in 2003.16 Similarly, in a large integrated US health care system, the incidence of diagnosed cases of Barrett's esophagus rose from 15 per 100,000 patient-years in 1998 to 24 per 100,000 in 2006.17 In the same population, the prevalence of diagnosed Barrett's esophagus rose from less than 10 per 100,000 individuals in 1994 to 131 per 100,000 in 2006, with no sign of plateauing. These figures need to be interpreted with caution because estimating the changing incidence of Barrett's esophagus is more challenging than estimating the changing incidence of esophageal adenocarcinoma. Changes in the incidence of diagnosed Barrett's esophagus can be strongly influenced by changing patterns in the practice of upper endoscopy, both in terms of who gets referred for the procedure and which endoscopic and histologic findings are recognized as Barrett's esophagus. Hence, the proportion of individuals with Barrett's esophagus who are diagnosed with Barrett's esophagus has likely been increasing over the last few decades. Indeed, population-based studies of individuals invited to undergo upper endoscopy for research indicate that the true prevalence of Barrett's esophagus is much greater than suggested by the previously mentioned clinical studies, and at least...

Produkt-Details

• Erscheint lt. Verlag: 1.5.2014
• Sprache: englisch
• Themenwelt: Medizinische Fachgebiete ► Innere Medizin ► Gastroenterologie
• ISBN-10: 0-323-29029-9 / 0323290299
• ISBN-13: 978-0-323-29029-6 / 9780323290296