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Evaluation of elevation of the head of the bed, bethanechol, and antacid foam tablets on gastroesophageal reflux



To ascertain how elevation of the head of the bed, bethanechol, and antacid foam tablets affect gastroesophageal reflux, we used prolonged intraesophageal pH monitoring in 55 symptomatic patients. Acid exposure was separated into reflux frequency and esophageal acid clearance time and recorded during the day in the upright posture and recumbent at night. Values before and during each therapy were compared to physiologic reflux in 15 asymptomatic controls. Ten patients slept with the head of the bed elevated and had a 67% improvement in the acid clearance time (PPP
... The beneficial effects of elevating the head of the bed with either blocks or wedges when sleeping have been described for over 40 years now. 27 The rationale for elevating the head of the bed is to elevate the gastroesophageal junction sufficiently enough to avoid submersion of the area below liquid gastric contents. 28 Initial studies demonstrate that up to two-thirds of patients that sleep with an elevated head of the bed have improvement in esophageal acid clearance times, as measured by intraesophageal pH monitoring. ...
... This did translate into decreased esophageal acid exposure times, although it did not decrease the frequency of reflux episodes in patients that had elevation of the head of the bed while sleeping. 27 This has shown to correlate with decreased reported frequency of reflux symptoms in patients with GERD. [29][30][31][32] Three randomized controlled trials (level of evidence 1) have consistently shown esophageal pH values and GERD symptoms improve with elevation of the head of the bed. ...
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Objective The medical management of gastroesophageal reflux disease (GERD) continues to evolve. Our aim was to systematically assess the literature to provide an updated review of the evidence on lifestyle modifications and pharmacological therapy for the management of GERD. Background The cornerstones of GERD medical management consist of lifestyle modifications and pharmacologic agents. Most recently, evidence has emerged linking anti-reflux pharmacologic therapy to adverse events, such as kidney injury, metabolic bone disease, myocardial infarction, and even dementia, among others. Methods A systematic search of the databases of PubMed/MEDLINE, Embase, and Cochrane Library was performed for articles on the medical management of GERD between inception and March 1, 2021. Conclusion Although pharmacological therapy has been associated with potential adverse events, further research is needed to determine if this association exists. For this reason, lifestyle modifications should be considered first-line, while pharmacologic therapy can be considered in patients in whom lifestyle modifications have proven to be ineffective in controlling their symptoms or cannot institute them. Naturally, extra-esophageal causes for GERD-like symptoms must be considered on suspected high-risk patients and excluded before considering treatment for GERD.
... Elevation of head of the bed with blocks of 28 cm decreased the time the pH was below five, the number of reflux episodes, and acid clearance time, leading to symptomatic benefit [6]. However, the frequency of reflux episodes remained unchanged [7]. ...
... As mentioned above, the use of the bed wedges had no significant effect on the pH monitoring parameters used to assess acid gastro esophageal reflux. Previous investigations described that head of bed elevation is a correct treatment to decrease gastro esophageal reflux [4][5][6], however, others showed that the number of reflux episodes in supine position did not change with the elevation [7,8]. ...
... Elevating the bed head has been shown to promote oesophageal clearance, by gravity, reducing epithelial exposure time to the refluxate. This is particularly important in the presence o f a documented motility disorder and at night when the other mechanisms of clearance are comparitively delayed (Johnson et al, 1981). ...
There is little acknowledgement in the literature with regard to symptom expression in a non acidic pH range, in particular the neutral (4 - 7) pH range. Data from the current study suggests that 30% of patients with GORD and 38% with Barrett's CLO respectively, experienced the majority of their symptoms within a neutral (4 - 7) pH range. It is widely acknowledged that 90% of bile delivery to the distal oesophagus, arises in the neutral pH range. In addition, alkaline reflux has been significantly implicated in the sequelae of GORD, namely Barrett's CLO and oesophageal junctional adenocarcinoma. The reduction in mucosal sensitivity in Barrett's CLO to acid reflux is widely recognised. A reduction in mucosal sensitivity of the metaplastic epithelium to acid perfusion in GORD (p<0.001) and a control group (p<0.001) was confirmed and also to alkaline perfusion on comparison to a control group (p<0.01) alone. This may account for the large number of Barrett's CLO patients who present de novo with an associated complication such as a junctional adenocarcinoma. Antroduodenal dysmotility has been implicated in the pathogenesis of duodenogastro oesophageal reflux, which is relevant to bile delivery to the distal oesophagus. Non invasive assessment of antroduodenal motility, utilising electrogastrography (EGG ) and antral ultrasound, revealed marked antroduodenal dysmotility in both Barrett's CLO (p<0.01) and GORD (p<0.01) in the pre and post prandial phases, Barrett's CLO (p<0.001); GORD (p<0.05), in comparison to a control group. In addition, an increased prevalence of brady and tachyarrthymias was noted in Barrett's CLO, which was most marked in the post prandial phase. This may partly explain the increased presence of bile in the oesophageal refluxate in Barrett's CLO patients and thus their recognised increased morbidity. The rationale for the aggressive evaluation, of symptomatic reflux in a non acidic pH range, utilizing bilitec in combination with antroduodenal assessment and perhaps impedance in the future, is justified by the knowledge that patients who experience the majority of their symptoms within a non acidic pH range are increasingly prone to the serious sequelae of GORD. Such patients should be considered for anti reflux surgery as there is now increasing evidence supporting the prophylactic role of anti reflux surgery in the preventative management of junctional malignancy.
Esophageal diseases are common in all age groups, including the old. The diagnosis of esophageal disorders in older patients is complicated by changes brought about by “normal” aging. This chapter reviews changes in pharyngoesophageal function with aging and the unique aspects of esophageal diseases, including clinical presentation, diagnosis, and management, in older individuals. Many of the purported age‐related changes in the esophageal body, lower esophageal sphincter, and anatomy (hiatal hernia) predispose to gastroesophageal reflux disease (GERD). Because GERD is a chronic persistent disorder, it seems likely that the frequency of associated complications increases with increasing duration of disease and thus with age. Despite milder heartburn, older patients may be more likely to have severe esophagitis, strictures, and Barrett's esophagus. The aim of treatment of distal esophageal spasm is to correct peristaltic dysfunction and improve symptoms.
Gastroesophageal reflux disease (GERD) is a prevalent, chronic medical condition that affects 13% of the adult population globally at least once a week. Sleep disturbances are frequently encountered in up to 25% of the GERD patients, likely due to nocturnal gastroesophageal reflux (GER). With advance in diagnostic techniques allowing for an improved understanding of involved physiological mechanisms of nocturnal reflux, there is growing evidence of a bidirectional relationship between GERD and sleep disturbances. Furthermore, nocturnal GER is associated with more complicated GERD. Obstructive sleep apnea (OSA) and GERD also have been linked, but to what degree remains controversial. Treatment of nocturnal GER has been shown to improve both subjective and objective sleep measures. The therapeutic approach includes lifestyle modifications and medication individualization and optimization with proton-pump inhibitors serving as the mainstay of treatment. Antireflux surgery and newer endoscopic procedures have been demonstrated to control nocturnal GER.
Gastro-oedophageal reflux may be responsible for symptoms and sometimes for the development of oesophageal damage. These effects are inconstant when reflux is demonstrated by radiography or by conuentional pH studies. This unpredictability may be accounted for by the observation that during the day refluxed material is rapidly cleared from the oesophagus by swallowing, while during sleep little swallowing occurs. To explore the hypothesis that reflux during deep is the important factor, prolongedintra-oesophageal pH studies have been done and a method has been developed for quantifying nocturnal gastro-oesophageal reflux11. The investigation has Ahown that persistence of acid within the oesophagus is associated with prolonged periods during sleep when no swallowing occurs. Measurements of nocturnal intra-oesophageal pH were made in 41 patients with symptomatic sliding hiatus hernia. In 12 patients with mild symptoms reflux measured by this index did not exceed 15 minutes, with one exception, and no patient showed oesophagitis. In 10 patients with moderate symptoms reflux did not exceed 1 hour, with one exception, and mild to moderate oesophagitis was present in 4 cases. Nineteen patients had severe symptoms; in all hut one the period of reflux was in excess of 1 hour, and oesophagitis was found in 13.
: This study examined the effect of body position on lower esophageal sphincter (LES) pressure. In 36 healthy subjects and 31 patients with reflux esophagitis, LES and intragastric pressures were measured with subjects in the supine and sitting positions by the intraluminal microtransducer method. LES pressure was significantly lower in the sitting position than in the supine position in both healthy subjects and patients with reflux esophagitis. Intragastric pressure was significantly higher in the sitting position than in the supine position in both healthy subjects and patients with reflux esophagitis, but this increase was less marked than the decrease in LES pressure in the sitting position. The overlap of LES pressure values between healthy subjects and patients with reflux esophagitis was lower in the sitting position than in the supine position. We conclude that the measurement of LES pressure in the sitting position reflects LES function more accurately.
Exposure of the distal esophageal mucosa to acid gastric juice was quantitated by 24-hr pH monitoring in 100 individuals and was correlated with morphologic data derived from esophageal biopsies. The degree of acid exposure to the distal esophagus correlated directly with increases in both relative and absolute length of the subepithelial papillae and to relative basal zone hyperplasia. Both papillary length and basal zone hyperplasia decreased after antireflux surgery had reduced acid exposure to normal. Reflux in the recumbent position resulted in prolonged exposure of the mucosa to acid because of poor acid clearing from the esophagus. This caused longer papillae than did upright reflux, where there were more frequent reflux episodes, but with rapid acid clearance. The presence of a hiatal hernia was associated with longer papilae, lower DES pressure, increased reflux frequency, and prolonged recumbent acid clearance. Twenty-four hour pH monitoring correlated better with papillary length than did symptoms or other clinical measures of gastroesophageal reflux.
In this study we determined the acute effect of bethanechol (5 mg SC) on gastroesophageal reflux (GER) and lower esophageal sphincter pressure (LESP) in 27 patients with symptomatic esophagitis. The effect of bethanechol on esophageal acid clearance was also determined in 7 of the patients. Intraluminal pH monitoring prior to bethanechol administration demonstrated free or stress-induced reflux episodes in 18 of the 27 patients. Following bethanechol (1) LESP increased significantly, (2) GER diminished or ceased in many of the patients, and (3) acid clearance times decreased significantly. Some individuals, however, continued to reflux despite LESP elevation to 30 mm Hg or more. This latter finding suggests that LESP alone is not the sole factor governing LES competency. Other factors such as improved esophageal emptying may also contribute to the beneficial therapeutic effect of bethanechol in patients with heartburn.
Fifteen normal volunteers without symptoms of gastroesophageal reflux and sixteen patients with symptoms of gastroesophageal reflux unresponsive to medical management and having endoscopic esophagitis had esophageal manometry and twenty-four hour pH monitoring of the distal esophagus. The symptomatic patients underwent a Nissen antireflux procedure and were restudied at four months. After surgery, patients had less reflux, a higher sphincteric pressure, and an equal amount of sphincter within the abdomen as did asymptomatic control subjects.
Twenty-four pH monitoring the distal esophagus quantitates gastroesophageal reflux in a near physiologic setting by measuring the frequency and duration of acid exposure to the esophageal mucosa. Fifteen asymptomatic volunteers were studies with 24-hour pH and esophageal manometry. The normal cardia was more competent supine than in the upright position. Physiologic reflux was unaffected by age, rarely occurred during slumber, and was the rule after alimentation. One hundred symptomatic pateitns with an abnormal 24-hour pH record (2 S.D. above the mean of controls) could be divided into three patterns of pathological reflux: those who refluxed only in the upright position (9), only in the supine position (37), and in both positions (54). Upright differed from supine refluxers by excessive aerophagia causing reflux episodes by repetitive belching. Compared to controls, they had excessive post-prandial reflux, lower DES pressure, and less DES exposed to the positive pressure of the abdomen. Supine differed from upright refluxers by having a higher incidence of esophagitis and an inability to clear the esophagus of acid after a supine reflux episode. Compared to controls, they had only a lower DES pressure. Combined refluxers had a higher incidence of esophagitis than supine refluxers. Stricture (15%) was seen only in this group. They were similar to supine refluxers in their inability to clear a supine reflux episode. Compared to controls, they had a lower DES pressure and less DES exposed to the positive pressure of the abdomen. Forty of the 100 patients had an antireflux procedure (4 upright, 8 supine, 28 combined). The most severe postoperative flatus and abdominal distention was seen in the upright refluxers. It is concluded that minimal reflux is physiological. Patients with pathological reflux all have lower DES pressure. Patients with upright reflux have less of their DES exposed to the positive pressure environment of the abdomen. Patients with supine reflux have an inability to clear the esophagus of reflux acid and are prone to develop esophagitis. Patients with both upright and supine reflux have the most severe disease and are at risk in developing strictures. In patients with only upright reflux, aerophagia and delayed gastric emptying may be an important etiological factor.
Intraluminal pH in the lower esophagus has been recorded during a 3-hr period following a ligh meal and a consecutive 12-hr nocturnal period in 20 patients with typical symptoms and radiological evidence of gastroesophageal reflux and in 10 patients without such signs of reflux. Evidence of acid reflux was obtained in 3 of the patients without reflux during the postcibal period but in only one during the 12-hr nocturnal period. In contrast all except one of the 20 patients who had evidence of reflux showed spells of high acidity both in the postcibal and nocturnal periods. There was no clear correlation between the frequency of paf high acidity in the nocturnal period. Those patients with endoscopic evidence of severe esophagitis showed a significantly longer duration of high esophageal acidity in the nocturnal period. We conclude that nocturnal exposure of the esophageal mucosa to acid is a major factor in the causation of reflux esophagitis.