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Effect of bed head elevation during sleep in symptomatic patients of nocturnal gastroesophageal reflux
Abstract
Nocturnal gastro-esophageal reflux causes heartburn and sleep disturbances impairing quality of life. Lifestyle modifications, like bed head elevation during sleep, are thought to alleviate the symptoms of gastroesophageal reflux. We tested the hypothesis that bed head elevation might decrease recumbent acid exposure compared to sleeping in a flat bed.
Patients of symptomatic nocturnal reflux and documented recumbent (supine) reflux verified by esophageal pH test entered the trial. On day 1, baseline pH was measured while the patient slept on a flat bed. Then patients slept on a bed with the head end elevated by a 20-cm block for the next 6 consecutive days from day 2 to day 7. The pH test was repeated on day 2 and day 7. Each patient acted as his own control.
Twenty of 24 (83.3%) patients with mean age of 36 ± 5.5 years completed the trial. The mean (± SD) supine reflux time %, acid clearance time, number of refluxes 5 min longer and symptom score on day 1 and day 7 were 15.0 ± 8.4 and 13.7 ± 7.2; P = 0.001, 3.8 ± 2.0 and 3.0 ± 1.6; P = 0.001, 3.3 ± 2.2 and 1.0 ± 1.2; P = 0.001, and 2.3 ± 0.6 and 1.5 ± 0.6; P = 0.04, respectively. The sleep disturbances improved in 13 (65%) patients.
Bed head elevation reduced esophageal acid exposure and acid clearance time in nocturnal (supine) refluxers and led to some relief from heartburn and sleep disturbance.
... We identified five randomized clinical trials and one non-randomized clinical trial that investigated the effect of head of bed elevation on nocturnal reflux (Table 1). [19][20][21][22][23] Two studies used esophageal pH parameters as outcome measure. In a cross-over study with 15 endoscopically proven reflux esophagitis patients, patients slept three consecutive nights, in random order, in a hospital bed with a wedge (22° angle), bed blocks (20 cm), or without elevation (one pillow). ...
... In a non-randomized trial in 20 patients with confirmed nocturnal esophageal reflux by pH testing, two weeks of bed blocks led to a minimal, but significant, reduction in time with pH <4 (%) from 15.0 ± 8.4 versus to 13.7 ± 7.2 (p = 0.001). 23 These studies suggest F I G U R E 1 PRISMA flow diagram. Number of studies identified by search strategy and final number of studies included in the systematic review. ...
Background:
Nocturnal gastroesophageal reflux symptoms have a major impact on sleep quality and are associated with complicated gastroesophageal reflux disease (GERD). We performed a systematic review to assess the data on the effectiveness of the currently available interventions for the treatment of nocturnal reflux symptoms.
Methods:
We searched PubMed, EMBASE, and the Cochrane Library. All prospective, controlled, and uncontrolled clinical trials in adult patients describing interventions (lifestyle modifications, surgical and pharmacological) for nocturnal gastroesophageal reflux symptoms were assessed for eligibility. A narrative descriptive summary of findings is presented together with summary tables for study characteristics and quality assessment.
Key results:
The initial reference search yielded 3067 citations; 66 citations were screened in full text, of which 31 articles were included. Studies on lifestyle modifications include head of bed elevation (n = 5), prolonging dinner-to-bed time (n = 2), and promoting left lateral decubitus position (n = 2). Placebo-controlled clinical trials investigating proton pump inhibitors (PPIs) (n = 11) show success rates ranging from 34.4% to 80.8% in the PPI group versus 10.4%-51.7% in the placebo group. Laparoscopic fundoplication is reserved for severe disease only. There is insufficient evidence for a recommendation on the use of nasal continuous positive airway pressure (nCPAP), hypnotics, baclofen and adding bedtime H2 receptor antagonists for reducing nocturnal reflux. CONCLUSION INFERENCES: A sequential treatment strategy, including head of bed elevation, prolonging dinner-to-bed time, promoting left lateral decubitus position and treatment with acid-suppressive medication is recommended for nocturnal gastroesophageal reflux symptoms. Currently, there is insufficient evidence for the use of nCPAP, hypnotics, baclofen and adding bedtime H2 receptor antagonists.
... Elevation of the head of the bed (15 cm (17,69) . PPIs have been widely used for decades, but the number of recent publications questioning their safety has increased dramatically, causing considerable patient anxiety. ...
... Acid leak is frequently observed with the most currently used PPIs, whose pharmacokinetic characteristic involve the release of the drug at a single time point when used in a single daily dose in the morning. Although increasing the PPI dose to two daily doses is a common medical procedure, patients may eventually continue to experience symptoms related to nocturnal acid leak (69) . ...
Gastroesophageal reflux disease (GERD) presents typical manifestations such as heartburn and/or regurgitation as well as atypical manifestations such as throat symptoms, laryngitis, hoarseness, chronic cough, asthma, and sleep alterations. There are two phenotypes of the disease: erosive GERD, when erosions are identified by upper digestive endoscopy, and non-erosive GERD, when the esophageal mucosa presents a normal endoscopic aspect. Relevant clinical findings are usually absent in the physical examination, but it should be highlighted that obesity is an important aggravating factor of reflux. The treatment is established based on clinical findings and, according to the clinical situation, on complementary exams such as upper digestive endoscopy. In dubious cases where a precise diagnosis is required, the indicated test is esophageal pHmetry or impedance-pHmetry. Clinical treatment is divided into behavioral/dietary measures and pharmacological measures. Most patients benefit from clinical treatment, but surgical treatment may be indicated in the presence of a larger hiatal hernia and complications of the disease.
... 9 Acid clearance time (ACT), calculated by dividing the total acid exposure duration by the number of reflux episodes at each site, has also been used as an indicator of esophageal chemical clearance in some studies. [11][12][13][14] Because impaired chemical clearance plays an important role in GERD, 6,7 the PSPW index and ACT are thought to be important parameters in understanding the pathogenesis of GERD. ...
... The ACT was calculated by dividing the total acid exposure duration in minutes by the number of reflux episodes at each site. [11][12][13][14] ACT was only examined in patients who underwent MII-pH testing after cessation of PPI treatment for seven or more days because ACT and AET are affected by PPI. ...
Ineffective esophageal motility (IEM) is the most common manometric abnormality in gastroesophageal reflux disease (GERD). However, the impact of IEM on esophageal chemical clearance has not been fully investigated. This study aimed to determine the impact of IEM on esophageal chemical clearance in patients with GERD. A total of 369 patients with GERD symptoms who underwent upper endoscopy and high-resolution manometry (HRM) test were retrospectively analyzed. The relationship between IEM and erosive esophagitis was examined. In addition, the impact of IEM on chemical clearance was examined in patients who underwent an additional combined multichannel intraluminal impedance-pH (MII-pH) test. Esophageal chemical clearance capability was evaluated via postreflux swallow-induced peristaltic wave (PSPW) index and acid clearance time (ACT). Of 369 patients, 181 (49.1%) had esophageal motility disorders, of which 78 (21.1%) had IEM. The proportion of IEM patients in those with erosive esophagitis and those without were 16.2% and 21.7%, respectively, and no significant difference was observed (P = 0.53). After excluding patients other than those with IEM and normal esophageal motility, 64 subsequently underwent MII-pH test. The median values of the PSPW index in the IEM and normal esophageal motility group were 11.1% (4.2%-20.0%) and 17.1% (9.8%-30.6%), respectively. The PSPW index was significantly lower in the IEM group than in the normal esophageal motility group (P < 0.05). The median ACT values in the IEM group and normal esophageal motility group were 125.5 (54.0-183.5) seconds and 60.0 (27.2-105.7) seconds, respectively. The ACT was significantly longer in the IEM group than in the normal esophageal motility group (P < 0.05). In conclusion, IEM was found to be associated with chemical clearance dysfunction as measured against the PSPW index and ACT. As this condition could be a risk factor for GERD, future treatments should be developed with a focus on chemical clearance.
... 9 Acid clearance time (ACT), calculated by dividing the total acid exposure duration by the number of reflux episodes at each site, has also been used as an indicator of esophageal chemical clearance in some studies. [11][12][13][14] Because impaired chemical clearance plays an important role in GERD, 6,7 the PSPW index and ACT are thought to be important parameters in understanding the pathogenesis of GERD. ...
... The ACT was calculated by dividing the total acid exposure duration in minutes by the number of reflux episodes at each site. [11][12][13][14] ACT was only examined in patients who underwent MII-pH testing after cessation of PPI treatment for seven or more days because ACT and AET are affected by PPI. ...
Background
Achalasia is a rare disease characterized by absent esophageal motility and disorder of lower esophageal sphincter (LES) relaxation. The Chicago Classification, version 3.0 presents the diagnostic criteria for achalasia using high-resolution manometry (HRM) as well as categorizes this disease into three types with different esophageal motility patterns.
Methods
A case-series study was conducted at the Institute of Gastroenterology and Hepatology on patients suspected achalasia on upper endoscopy or esophageal barium X-ray. Symptom severity was evaluated by the Eckardt score before and after treatment. Achalasia was diagnosed and classified by HRM using the Chicago Classification version 3.0.
Results
From April to December 2018, we recruited 20 patients (7 males and 13 females; the mean age were 35.9 ± 15.4). There were 4 patients (20%) diagnosed with absent contractility on HRM. In 16 achalasia confirmed patients, the percentage of type I, II, and III was 12.5%, 75%, and 12.5%, respectively. The mean Eckardt score before treatment was 6.6 ± 2.6 and there was no difference between achalasia and absent contractility groups. The integrated relaxation pressure within 4s (IRP4s) in achalasia group was high with the mean value being 24.6 ± 6.3 mmHg and there was no difference among three types. There was a significant improvement of clinical symptoms with pre and post-treatment Eckardt score being 6.8 ± 2.8 and 2.1 ± 1.9, respectively (p < 0.05). In 2 cases after surgery and balloon dilation, the LES pressure was normal but absent contractility and distal esophageal spasm were present on HRM.
Conclusions
High-resolution manometry is a valuable exploratory test for definitive diagnosis, classification as well as follow-up after treatment on achalasia patients.
... This allows the refluxed contents to move orad and remain in the esophagus longer. Khan et al. [37] found that elevating the head end of the bed with wooden blocks of 20 cm in patients with symptomatic nocturnal reflux resulted in significantly decreasing the mean (SD) supine reflux time from 15% (8.4) to 13.7% (7.2). The acid clearance time was significantly reduced from 3.8 (2) to 2 (1.6) min. ...
... wedge was associated with significantly less acid reflux time that esophageal pH was less than 4 [39]. In a study from northern India, head end of the bed elevation with a 20-cm block for one week reduced esophageal acid exposure and acid clearance time in nocturnal refluxers and led to some improvement in heartburn and sleep [37]. However, in another RCT, there was no improvement with head end of the bed elevation in terms of symptom control [40]. ...
The Indian Society of Gastroenterology developed this evidence-based practice guideline for management of gastroesophageal reflux disease (GERD) in adults. A modified Delphi process was used to develop this consensus containing 58 statements, which were generated by electronic voting iteration as well as face-to-face meeting and review of the supporting literature primarily from India. These statements include 10 on epidemiology, 8 on clinical presentation, 10 on investigations, 23 on treatment (including medical, endoscopic, and surgical modalities), and 7 on complications of GERD. When the proportion of those who voted either to accept completely or with minor reservation was 80% or higher, the statement was regarded as accepted. The prevalence of GERD in India ranges from 7.6% to 30%, being < 10% in most population studies, and higher in cohort studies. The dietary factors associated with GERD include use of spices and non-vegetarian food. Helicobacter pylori is thought to have a negative relation with GERD; H. pylori negative patients have higher grade of symptoms of GERD and esophagitis. Less than 10% of GERD patients in India have erosive esophagitis. In patients with occasional or mild symptoms, antacids and histamine H2 receptor blockers (H2RAs) may be used, and proton pump inhibitors (PPI) should be used in patients with frequent or severe symptoms. Prokinetics have limited proven role in management of GERD.
... Tampoco encontramos evidencia concluyente con otras medidas como elevar la cabecera de la cama. Solo encontramos un ensayo clínico no controlado a favor de la mejoría de los síntomas (127). Una de las medidas más investigadas fue disminuir de peso, ya que la relación de sobrepeso/ obesidad y ERGE ha sido bastante estudiada y en muchos casos encontrando una asociación positiva. ...
... El promedio (DE) de la fracción de tiempo de pH <4,0 en día 1 y el día 7 fue 15,0 (8,4) y 13,7 (7,2) respectivamente (p= 0,001). En el día 1, 14 pacientes tenían pirosis moderada, 5 moderada-severa y 1 severa, mientras que al completar los 7 días, 12 tenían pirosis moderada, 7 leve y 1 tuvo resolución completa (127). ...
... Tampoco encontramos evidencia concluyente con otras medidas como elevar la cabecera de la cama. Solo encontramos un ensayo clínico no controlado a favor de la mejoría de los síntomas (127). Una de las medidas más investigadas fue disminuir de peso, ya que la relación de sobrepeso/ obesidad y ERGE ha sido bastante estudiada y en muchos casos encontrando una asociación positiva. ...
... El promedio (DE) de la fracción de tiempo de pH <4,0 en día 1 y el día 7 fue 15,0 (8,4) y 13,7 (7,2) respectivamente (p= 0,001). En el día 1, 14 pacientes tenían pirosis moderada, 5 moderada-severa y 1 severa, mientras que al completar los 7 días, 12 tenían pirosis moderada, 7 leve y 1 tuvo resolución completa (127). ...
... 15,17,27 While there is limited evidence to support the effectiveness of these interventions, they may provide broader health benefits to the individual and they carry no risk for adverse consequences. These lifestyle modifications include healthy eating and weight reduction (for those with a body mass index >30 kg/m 2 or those who have recently gained 32,33 , participating in strenuous physical activity after eating 34 , raising the head of the bed during sleep (particularly if nocturnal reflux symptoms are present) 32,33 or avoiding restrictive clothing 27 , and not avoiding eating for a few hours before bedtime. 27,35 Avoiding known precipitants, including alcohol, coffee, and chocolate, as well as fatty, acidic, or spicy foods, is often recommended; however, because there is limited evidence to support the efficacy of these interventions, the American College of Gastroenterology endorsed only a conditional recommendation for this approach to treating GERD. ...
... 15,17,27 While there is limited evidence to support the effectiveness of these interventions, they may provide broader health benefits to the individual and they carry no risk for adverse consequences. These lifestyle modifications include healthy eating and weight reduction (for those with a body mass index >30 kg/m 2 or those who have recently gained 32,33 , participating in strenuous physical activity after eating 34 , raising the head of the bed during sleep (particularly if nocturnal reflux symptoms are present) 32,33 or avoiding restrictive clothing 27 , and not avoiding eating for a few hours before bedtime. 27,35 Avoiding known precipitants, including alcohol, coffee, and chocolate, as well as fatty, acidic, or spicy foods, is often recommended; however, because there is limited evidence to support the efficacy of these interventions, the American College of Gastroenterology endorsed only a conditional recommendation for this approach to treating GERD. ...
Heartburn and acid regurgitation are the cardinal symptoms of gastroesophageal reflux and occur commonly in the Canadian population. Multiple non-prescription treatment options are available for managing these symptoms, including antacids, alginates, histamine-H2 receptor antagonists (H2RAs), and proton-pump inhibitors (PPIs). As a result, pharmacists are ideally positioned to recommend appropriate treatment options based upon an individual’s needs and presenting symptoms, prior treatment response, comorbid medical conditions, and other relevant factors. Individuals who experience mild heartburn and/or have symptoms that occur predictably in response to known precipitating factors can manage their symptoms by avoiding known triggers and using on-demand antacids and/or alginates or lower-dose non-prescription H2RAs (e.g. ranitidine 150 mg). For those with moderate symptoms, lifestyle changes, in conjunction with higher-dose non-prescription H2RAs, may be effective. However, for individuals with moderate-to-severe symptoms that occur frequently (i.e. ≥2 days/week), the non-prescription (Schedule II) PPI omeprazole 20 mg should be considered. The pharmacist can provide important support by inquiring about the frequency and severity of symptoms, identifying an appropriate treatment option, and recognizing other potential causes of symptoms, as well as alarm features and atypical symptoms that would necessitate referral to a physician. After recommending an appropriate treatment, the pharmacist can provide instructions for its correct use. Additionally, the pharmacist should inquire about recurrences, respond to questions about adverse events, provide monitoring parameters, and counsel on when referral to a physician is warranted. Pharmacists are an essential resource for individuals experiencing heartburn; they play a crucial role in helping individuals make informed self-care decisions and educating them to ensure that therapy is used in an optimal, safe, and effective manner.
... The use of a wedge-shaped pillow (WSP) alleviates reflux symptoms in patients with esophageal cancer following esophagectomy and reconstruction. Likewise, the combined treatment (antisecretory drugs + WSP) also reduces the severity of esophagitis [143]; o Several studies show that sleeping with the head of the bed elevated or on a wedge reduces GER and lying left-side down reduces GER versus lying right-side down and supine [144]. The left lateral position is a suitable alternative to prone for the postural management of infants with symptomatic GER [145]; o Finally, bed head elevation by reducing the time of acid exposure also alleviates the consequences of nocturnal supraesophageal reflux, including perennial nasopharyngitis, cough, and asthma [146]. ...
The esophagus is the centerpiece of the digestive system of individuals and plays an essential role in transporting swallowed nutrients to the stomach. Diseases of the esophagus can alter this mechanism either by causing anatomical damage that obstructs the lumen of the organ (e.g., peptic, or eosinophilic stricture) or by generating severe motility disorders that impair the progression of the alimentary bolus (e.g., severe dysphagia of neurological origin or achalasia). In all cases, nutrient assimilation may be compromised. In some cases (e.g., ingestion of corrosive agents), a hypercatabolic state is generated, which increases resting energy expenditure. This manuscript reviews current clinical guidelines on the dietary and nutritional management of esophageal disorders such as severe oropharyngeal dysphagia, achalasia, eosinophilic esophagitis, lesions by caustics, and gastroesophageal reflux disease and its complications (Barrett’s esophagus and adenocarcinoma). The importance of nutritional support in improving outcomes is also highlighted.
... More research is needed into the role of weight loss in treating or lowering extraesophageal symptoms. One study suggests that lying to the right increases nocturnal reflux and postprandial reflux and recommends that patients avoid sleeping lying to the right (Khan et al., 2012;Person et al., 2015;Allampati et al., 2017). Another large cohort study showed that quitting smoking improved GERD symptoms (Ness-Jensen et al., 2014). ...
GERD, or gastroesophageal reflux disease, is a prevalent medical condition that affects millions of individuals throughout the world. Chronic cough is often caused by GERD, and chronic cough caused by GER is defined as GERD-related chronic cough (GERC). It is still unclear what the underlying molecular mechanism behind GERC is. Reflux theory, reflex theory, airway allergies, and the novel mechanism of esophageal motility disorders are all assumed to be linked to GERC. Multichannel intraluminal impedance combined with pH monitoring remains the gold standard for the diagnosis of GERC, but is not well tolerated by patients due to its invasive nature. Recent discoveries of new impedance markers and new techniques (mucosal impedance testing, salivary pepsin, real-time MRI and narrow band imaging) show promises in the diagnosis of GERD, but the role in GERC needs further investigation. Advances in pharmacological treatment include potassium-competitive acid blockers and neuromodulators (such as Baclofen and Gabapentin), prokinetics and herbal medicines, as well as non-pharmacological treatments (such as lifestyle changes and respiratory exercises). More options have been provided for the treatment of GERC other than acid suppression therapy and anti-reflux surgery. In this review, we attempt to review recent advances in GERC mechanism, diagnosis, and subsequent treatment options, so as to provide guidance for management of GERC.
... Pathology of the esophagus may lead to laryngeal or pharyngeal cancer (Qadeer et al., 2005). Previous studies have found that head elevation during sleep reduced esophageal acid exposure, providing relief from heartburn and long sleep and therefore improving the quality of life (Khan et al., 2012). ...
This study was aimed to explore the synthesis of sol titanium dioxide and silver nanoparticles (TiO2-AgNPs) to develop rubber latex pillows according to ergonomics so that they possess self-cleaning properties and antibacterial activities to relieve acid reflux and enhance the ability to remove any dirt or bacteria. TiO2-AgNPs at AgNP concentration of 10 ppm coated on the surface of rubber latex ergonomic pillows were found the most suitable concentration that was effective for self-cleaning and MRSA inhibition. Self-cleaning properties were measured by the degradation of methylene blue for 90 minutes, TiO2-AgNP coated samples at AgNP concentration of 10 ppm degraded 44.2% of methylene blue under UV-A light, while samples not coated with TiO2-AgNP degraded 2% of methylene blue. Samples coated with TiO2-AgNP at AgNP concentration of 10 ppm were tested for inhibition of MRSA by the agar well diffusion method. Results showed the highest inhibition radii of 4.5 mm. Skin contact allergy patch tests in 20 volunteers showed no skin symptoms. According to the satisfaction analysis, the use of self-cleaning and antibacterial anti-reflux rubber pillows yielded a relatively high level of satisfaction ( = 4.19, S.D. = 0.46), compared with that of general rubber pillows.
... Положение тела, которое человек занимает после еды также имеет значение в возникновении рефлюксов. Показано, что пациенты с рефлюкс-эзофагитом, по данным суточного мониторинга рН, испытывают большее количество рефлюксов в горизонтальном положении [42], а изменение позы для сна, т. е. поднятие головного конца кровати на 20 см или положение лежа на левом боку [43], может эффективно сократить время кислотного рефлюкса, время клиренса кислоты и количество рефлюксов >5 мин [44], из чего следует, что положение тела имеет важное значение как в возникновении симптомов рефлюксной болезни, так и в их профилактике. ...
Gastroesophageal reflux disease (GERD) is one of the most common causes of health care seeking at the primary care level in many countries. At an epidemiological level, GERD has been shown to be associated with a number of risk factors: obesity, tobacco smoking, alcohol abuse, certain patterns of eating behaviour, and the use of several medications. GERD is now regarded as a heterogeneous disease and includes different phenotypes (erosive reflux disease, non-erosive reflux disease, hypersensitive oesophagus, functional heartburn), the proper diagnosis of which improves the effectiveness of therapy in patients with heartburn symptoms. Daily impedance–pH monitoring is known to be an integral part of the diagnostic algorithm for GERD and is a functional diagnostic method to record all types of refluxes entering the oesophagus regardless of pH, to assess their association with symptoms, and to determine whether patients with heartburn symptoms belong to a particular phenotype. Esophageal manometry plays a key role in the evaluation of patients with heartburn symptoms, as it helps to rule out other conditions that may mimic GERD: achalasia cardia and scleroderma esophagus. This technique is used to assess thoracic esophageal motility and sphincter function and in the assessment of patients prior to antireflux surgery or in the refractory course of GERD. The article describes in detail GERD risk factors (triggers of heartburn), as well as diagnostic aspects, taking into account a differentiated approach to patients with heartburn based on daily impedance–pH monitoring data in accordance with the current guidelines and recommendations.
... This sleeping position is thought to lead to benefits by decreasing upper airway collapsibility and increasing the upper airway area, compared to the flat position, leading to improved breathing and, in turn, better sleep [5]. Elevating the upper body at night is also frequently recommended to alleviate heartburn symptoms and improve sleep in individuals experiencing nocturnal gastroesophageal reflux [14]. This nonpharmacologic approach is preferred by many patients. ...
Background
Accurately and unobtrusively testing the effects of snoring and sleep interventions at home has become possible with recent advances in digital measurement technologies.
Objective
The aim of this study was to examine the effectiveness of using an adjustable bed base to sleep with the upper body in an inclined position to reduce snoring and improve sleep, measured at home using commercially available trackers.
Methods
Self-reported snorers (N=25) monitored their snoring and sleep nightly and completed questionnaires daily for 8 weeks. They slept flat for the first 4 weeks, then used an adjustable bed base to sleep with the upper body at a 12-degree incline for the next 4 weeks.
Results
Over 1000 nights of data were analyzed. Objective snoring data showed a 7% relative reduction in snoring duration (P=.001) in the inclined position. Objective sleep data showed 4% fewer awakenings (P=.04) and a 5% increase in the proportion of time spent in deep sleep (P=.02) in the inclined position. Consistent with these objective findings, snoring and sleep measured by self-report improved.
Conclusions
New measurement technologies allow intervention studies to be conducted in the comfort of research participants’ own bedrooms. This study showed that sleeping at an incline has potential as a nonobtrusive means of reducing snoring and improving sleep in a nonclinical snoring population.
... It has been reported that sleep in an angle-adjustable chair, such as a recliner, improved the sleep quality through the sleep at a higher angle of posture or the neck [20][21][22]. In particular, it has been proven that some sleep disorders could be medically improved in patients with sleep apnea [22][23][24][25] and nocturnal gastroesophageal reflux through sleep in a recliner [26]. In this paper, we propose an additional way to further improve the quality of sleep with providing a rocking motion to the recliner. ...
In this study, we analyze the effect of a recliner chair with rocking motions on sleep quality of naps using automated sleep scoring and spindle detection models. The quality of sleep corresponding to the two rocking motions was measured quantitatively and qualitatively. For the quantitative evaluation, we conducted a sleep parameter analysis based on the results of the estimated sleep stages obtained on the brainwave and spindle estimation, and a sleep survey assessment from the participants was analyzed for the qualitative evaluation. The analysis showed that sleep in the recliner chair with rocking motions positively increased the duration of the spindles and deep sleep stage, resulting in improved sleep quality.
... However, multiple studies, including several randomized controlled trials (RCTs), have demonstrated improvement in nocturnal GERD symptoms and nocturnal esophageal acid exposure with head of bed elevation or sleeping on a wedge. Also, compared with lying left-side down, lying right-side down increases nocturnal reflux and reflux after meals, presumably because right-sided recumbency places the EGJ in a dependent position relative to the pool of gastric contents that favors reflux (30,31).Thus, patients might be advised to avoid sleeping right-side down (32)(33)(34)(35). ...
Gastroesophageal reflux disease (GERD) continues to be among the most common diseases seen by gastroenterologists, surgeons, and primary care physicians. Our understanding of the varied presentations of GERD, enhancements in diagnostic testing, and approach to patient management have evolved. During this time, scrutiny of proton pump inhibitors (PPIs) has increased considerably. Although PPIs remain the medical treatment of choice for GERD, multiple publications have raised questions about adverse events, raising doubts about the safety of long-term use and increasing concern about overprescribing of PPIs. New data regarding the potential for surgical and endoscopic interventions have emerged. In this new document, we provide updated, evidence-based recommendations and practical guidance for the evaluation and management of GERD, including pharmacologic, lifestyle, surgical, and endoscopic management. The Grading of Recommendations, Assessment, Development, and Evaluation system was used to evaluate the evidence and the strength of recommendations. Key concepts and suggestions that as of this writing do not have sufficient evidence to grade are also provided.
... 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. The strength of this recommendation to elevate the head of the bed should be Grade A. ...
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.
... 59 A study revealed that bed-head elevation by 20 cm blocks reduced esophageal acid exposure and acid clearance time from baseline and led to some relief from heartburn and sleep disturbances. 70 In a recent study, head elevation significantly reduced reflux symptoms and night-time symptoms of patients treated on an outpatient basis with PPI compared with those sleeping without the elevation. 71 Statement 15: Alginates should be considered for empirical treatment of patients with mild-to-moderate symptoms of acid reflux disease Grade of recommendation: Strong Evidence level: High Consensus level: 100% (Strongly agree-80%; Agree with minor reservation-20%) ...
This paper reports the proceedings from the first consensus meeting on the management of mild‐to‐moderate gastroesophageal reflux disease (GERD) in the Southeast Asian (SEA) region. Seventeen statements were drawn up by a steering committee that focused on epidemiology, mechanism of action, diagnostic investigations, and treatment. Voting on the recommendations used the Delphi method with two rounds of voting among the 10 panel members. The consensus panel agreed that GERD is mostly a mild disease in the SEA region with predominantly non‐erosive reflux disease (NERD). Complicated GERD and Barrett's esophagus are infrequently seen. The panel recommended endoscopy in patients with alarm or refractory symptoms but cautioned that the incidence of gastric cancer is higher in SEA. pH and impedance measurements were not recommended for routine assessment. The acid pocket is recognized as an important pathogenic factor in GERD. Lifestyle measures such as weight reduction, avoidance of smoking, reduction of alcohol intake, and elevation of the head of the bed were recommended but strict avoidance of specific foods or drinks was not. Alginates was recommended as the first‐line treatment for patients with mild‐to‐moderate GERD while recognizing that proton‐pump inhibitors (PPIs) remained the mainstay of treatment of GERD. The use of alginates was also recommended as adjunctive therapy when GERD symptoms were only partially responsive to PPIs. Algorithm for the management of mild‐to‐moderate gastroesophageal reflux disease in the Southeast Asian region derived from the consensus statements and recommendations of an expert panel.
... Brief (≤ 2 h) periods of HDT up to -40˚seem well tolerated [64,65], but prolonged HDT at angles ≤ -12 % increases intracranial and intraocular pressure significantly [66]. Additionally, sufferers of gastric reflux should be aware that HDT could conceivably worsen symptomatology, given that elevating the head above bed level (the opposite of HDT) is an effective remedy [67][68][69][70]. This is likely not an issue for those who do not normally experience gastric reflux [71]. ...
Bodybuilding is a competitive endeavor where a combination of muscle size, symmetry, “conditioning” (low body fat levels), and stage presentation are judged. Success in bodybuilding requires that competitors achieve their peak physique during the day of competition. To this end, competitors have been reported to employ various peaking interventions during the final days leading to competition. Commonly reported peaking strategies include altering exercise and nutritional regimens, including manipulation of macronutrient, water, and electrolyte intake, as well as consumption of various dietary supplements. The primary goals for these interventions are to maximize muscle glycogen content, minimize subcutaneous water, and reduce the risk abdominal bloating to bring about a more aesthetically pleasing physique. Unfortunately, there is a dearth of evidence to support the commonly reported practices employed by bodybuilders during peak week. Hence, the purpose of this article is to critically review the current literature as to the scientific support for pre-contest peaking protocols most commonly employed by bodybuilders and provide evidence-based recommendations as safe and effective strategies on the topic.
... -In patients with suspected chronic cough due to a refluxcough syndrome, we recommend the following treatment: (1) diet modification to promote weight loss in patients who are overweight or obese; (2) head of bed elevation 24 and avoiding meals within 3 hours of bedtime 25 . ...
Cough is the most common respiratory symptom that can result from various causes, and is a major clinical problem that reduces patients' quality of life. Thus, clinical guidelines for the treatment of cough were established in 2014 by the cough guideline committee under the Korean Academy of Tuberculosis and Respiratory Diseases. From October 2018 to July 2020, the cough guidelines were revised by the members of the committee based on the first guidelines. The purpose of these guidelines is to help clinicians efficiently diagnose and treat patients with cough. This article highlights the recommendations and summary of the revised Korean cough guidelines. It includes a revised algorithm for the evaluation of acute, subacute, and chronic cough. For chronic cough, upper airway cough syndrome (UACS), cough variant asthma (CVA), and gastroesophageal reflux disease (GERD) should be considered in the differential diagnoses. If UACS is suspected, first-generation antihistamines and nasal decongestants can be used empirically. In cases with CVA, inhaled corticosteroids are recommended to improve the cough. In patients with suspected chronic cough due to symptomatic GERD, proton pump inhibitors are recommended. Chronic bronchitis, bronchiectasis, bronchiolitis, lung cancer, aspiration, intake of angiotensin-converting enzyme inhibitor, intake of dipeptidyl peptidase-4 inhibitor, habitual cough, psychogenic cough, interstitial lung disease, environmental and occupational factors, tuberculosis, obstructive sleep apnea, peritoneal dialysis, and unexplained cough can also be considered as causes of chronic cough. Chronic cough due to laryngeal dysfunction syndrome has been newly added to the guidelines.
... 88 Studies have shown that among patients with nocturnal acid reflux, changing the sleeping posture, ie, raising the head of the bed by 20 cm, can effectively reduce the acid reflux time, acid clearance time, and number of reflux events >5 min. 89 Another study showed that as a result of the use of a sleeppositioning device (SPD) among healthy subjects and the use of a left-side decubitus (SPD-L), the esophageal acid exposure time and reflux times were significantly lower than those associated with the right lateral position (SPD-R), any position with a standard wedge sleep aid device and the supine position. 90 An interval of less than 2 hours between dinner and sleep, eating 2 hours before bed, and an interval of less than 3 hours between dinner and sleep were positively correlated with GERD. ...
Mei Zhang,1 Zheng-Kun Hou,2 Zhi-Bang Huang,1 Xin-Lin Chen,3 Feng-Bin Liu2,4 1Graduate College, Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China; 2Gastroenterology Department, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China; 3Department of Preventive Medicine and Health Statistics, College of Basic Medical Science, Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China; 4Baiyun Hospital of the First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, ChinaCorrespondence: Zheng-Kun HouDepartment of Gastroenterology, The First Affiliated Hospital, Guangzhou University of Chinese Medicine, Guangzhou, 510405, Guangdong, ChinaTel +86 020– 36591314Email fenghou5128@126.comAbstract: We performed this review to clarify which dietary and lifestyle factors are related to gastroesophageal reflux disease. Through a systematic search of the PubMed, EMBASE, China National Knowledge Infrastructure (CNKI), and Chinese BioMedical Literature (CBM) databases, we identified articles with clear definitions of GERD, including nonerosive gastroesophageal reflux disease (NERD), reflux esophagitis (RE) and Barrett’s esophagus (BE), that included dietary and lifestyle factors as independent factors affecting the onset of GERD (expressed as odds ratios (ORs) or relative risks (RRs) and 95% confidence intervals (CIs)). Due to heterogeneity among the studies, we used descriptive statistical analyses to analyze and synthesize each outcome based on the disease type. In total, 72 articles were included, conducted in ten Western countries (26 articles in total) and nine Eastern countries (46 articles in total). We categorized dietary factors into 20 items and lifestyle factors into 11 items. GERD is related to many irregular dietary and lifestyle habits (such as a habit of midnight snacking: OR=5.08, 95% CI 4.03– 6.4; skipping breakfast: OR=2.7, 95% CI 2.17– 3.35; eating quickly: OR=4.06, 95% CI 3.11– 5.29; eating very hot foods: OR=1.81, 95% CI 1.37– 2.4; and eating beyond fullness: OR=2.85, 95% CI 2.18– 3.73). Vegetarian diets (consumption of nonvegetarian food (no/yes); OR=0.34, 95% CI 0.211– 0.545) and no intake of meat (OR=0.841, 95% CI 0.715– 0.990) were negatively related to GERD, while meat (daily meat, fish, and egg intake: OR=1.088, 95% CI 1.042-1.135) and fat (high–fat diet: OR=7.568, 95% CI 4.557– 8.908) consumption were positively related to GERD. An interval of less than three hours between dinner and bedtime (OR=7.45, 95% CI 3.38– 16.4) was positively related to GERD, and proper physical exercise (physical exercise > 30 minutes (> 3 times/week): OR=0.7, 95% CI 0.6– 0.9) was negatively correlated with GERD. Smoking (OR=1.19, 95% CI 1.12– 1.264), alcohol consumption (OR=1.278, 95% CI 1.207– 1.353) and mental state (poor mental state: OR=1.278, 95% CI 1.207– 1.353) were positively correlated with GERD. RE (vitamin C: OR=0.46, 95% CI=0.24– 0.90) and BE (vitamin C: OR=0.44,95% CI 0.2-0.98; vitamin E: OR=0.46, 95% CI 0.26– 0.83) were generally negatively correlated with antioxidant intake. In conclusion, many dietary and lifestyle factors affect the onset of GERD, and these factors differ among regions and disease types. These findings need to be further confirmed in subsequent studies.Keywords: gastroesophageal reflux disease, diet, lifestyle, systematic review
... 5,59 A crossover study of 30 patients randomized to a late meal (2 h before bedtime) vs. an early meal (6 hours before bedtime)showed significantly higher supine reflux on pH monitoring after the late evening meal (mean change 5.2%, p = 0.002), 217 supporting earlier dinner times in symptomatic GERD patients.A crossover RCT of 15 GERD participants showed that elevation of the head of the bed by a 10-inch wedge decreased esophageal AET compared to a flat position (15% and 21%, respectively, p < 0.05).218 Another study measuring the effect of 20-cm elevation of the head end of the bed demonstrated a significant but small effect on nocturnal acid exposure (15.0 ± 8.4 vs. 13.7 ± 7.2; p = 0.001) and symptom score.219 Both studies support elevating the head end of the bed while supine.Several studies have shown that reflux is more likely to occur in the right lateral position compared to the left lateral position.220,221 ...
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.
... There are some lifestyle changes that can reduce the intensity of symptoms, including smoking cessation, reduction of alcohol consumption, weight loss and particularly the reduction of abdominal obesity, avoidance of fatty foods and coffee consumption, and avoidance of eating late-night meals (5,(8)(9)(10)(11)(12)(13)(14)(15)(16). Posture during night sleep also appears to have a significant role in the improvement of symptoms; a bed head higher than 15-20 cm appears the least effective (1). ...
Gastroesophageal reflux disease (GERD) is a common gastrointestinal disorder requiring lifestyle adaptations and administration of medications. Another approach is the surgical treatment of GERD through laparoscopic or robotic operations. The aim of the present study was to investigate the improvement of symptoms and quality of life of patients with GERD, before and after robotic surgical restoration using the Nissen robotic fundoplication technique. The potential effects of body weight, age and sex, as well as the response to medications and progress over time, were also assessed. A retrospective study was conducted in a tertiary hospital between October 2019 and March 2020. Data were collected and recorded from 144 patients who underwent robotic surgery, using the Nissen fundoplication technique, during the period 2009-2019. All patients involved in this analysis pre-operatively exhibited severe symptoms of heartburn and reflux, as well as poor quality of life. All of these symptoms were re-examined after surgery, and a marked decrease was observed with respect to their frequency and intensity. Improvement was not affected by body mass index, whereas older patients exhibited greater improvement. Women initially experienced more severe symptoms before the surgery, but they appeared to respond as well as the male patients. The long-term beneficial effects of surgery for up to the 10-year period studied were validated. After the robotic surgical rehabilitation, the vast majority of patients overcame the unpleasant symptoms of GERD and stayed off their medications. More than 4/5 of the patients were satisfied after surgery. In conclusion, restoration of GERD, using Nissen robotic fundoplication, led to the minimization of symptoms and to a marked improvement in the quality of life of patients.
... 92,93 There is also reduced esophageal acid exposure and acid clearance time in nocturnal refluxers, and improvement in heartburn and sleep. 94 28. Patients of GERD should be advised not to lie down within 2 hours after a meal. ...
Gastroesophageal reflux disease (GERD) is a common problem in the community. The Indian Society of Gastroenterology and Association of Physicians of India have developed this evidence-based practice guideline for management of GERD in adults. A modified Delphi process was used to develop this consensus containing 43 statements, which were generated by electronic voting iteration as well as face-to-face meeting, and review of the supporting literature primarily from India. These statements include 4 on epidemiology, 9 on clinical presentation, 11 on investigations, 18 on treatment (including medical, endoscopic, and surgical modalities), and one on complications of GERD. The statement was regarded as accepted when the proportion of those who voted either to accept completely or with minor reservation was 80% or higher. The prevalence of GERD in large population-based studies in India is approximately 10% and is probably increasing due to lifestyle changes and increase in obesity. The diagnosis of GERD in the community should be mainly based on presence of classical symptoms like heartburn and sour regurgitation, and empiric treatment with a proton pump inhibitor (PPI) or H2 receptor antagonist should be given. All PPIs in equipotent doses are similar in their efficacy in the management of symptoms. Patients in whom symptoms do not respond adequately to PPI are regarded as having PPIrefractory GERD. Invasive investigations should be limited to patients with alarm symptoms and those with refractory GERD.
... Other studies have promoted elevating the head of the bed, sleeping in the left decubitus position, and, in those with nocturnal GERD symptoms, avoiding meals in the 2 to 3 hours before bedtime. 23,24 A sleep positional therapy device has been shown to reduce acid exposure times and improve nocturnal refl ux symptoms. 25,26 This device places the user in the left decubitus position at an incline and has been an effective tool for those with nocturnal symptoms. ...
Gastroesophageal reflux disease (GERD) is mainly a clinical diagnosis based on typical symptoms of heartburn and acid regurgitation. Current guidelines indicate that patients with typical symptoms should first try a proton pump inhibitor (PPI). If reflux symptoms persist after 8 weeks on a PPI, endoscopy of the esophagus is recommended, with biopsies taken to rule out eosinophilic esophagitis. This review discusses the evidence for different medical, endoscopic, and surgical therapies and presents a management algorithm.
... Alcohol consumption has a direct noxious effect on the esophageal epithelium in basic science studies [18,19]; however, the risk is unclear in epidemiologic studies. The cessation of both is advisable [68]. 5. Left lateral position and head elevation are important to protect against night-time reflux, but difficult to adapt and disruptive to the quality of sleep [69]. Their long-term effects are not clear. ...
The pathogenesis of gastroesophageal reflux disease has been explained by acid-peptic model. However, related with the progress of the diagnostic modalities, another phenotypical group of patients were defined and called "functional disorders of the esophagus". These patients are important because diagnosis is particularly difficult, co-morbid disorders especially psychiatric diseases are common, proton pump inhibitor response is low, and surgical results are very poor. Simpler and translational science studies are required in functional groups in order to differentiate from acid-peptic disorders. New and more accurate diagnostic modalities as well as therapeutic approaches are strongly needed in this particularly new and exciting era, especially in the effect of neuromodulators. Current diagnostic modalities should also be evaluated and in fact, normal values should be established. New medications, especially acting at the level of esophageal epithelium and intercellular spaces, might shift the paradigm.
... 27,28 The only proven lifestyle modification for the management of GERD is head of bed (HOB) elevation. 29 Head of bed elevation has been shown to decrease esophageal acid exposure and esophageal clearance time with subsequent reduction in symptoms in patients with supine GERD. In addition, is it advised that factors contributing to the incidence of TLESRs should also be minimized or avoided. ...
Gastroesophageal reflux disease (GERD) is a common clinical problem, affecting millions of people worldwide. Patients are recognized by both classic and atypical symptoms. Acid suppressive therapy provides symptomatic relief and prevents complications in many individuals with GERD. Advances in diagnostic and therapeutic modalities have improved our ability to identify and manage disease complications. Here, we discuss the pathophysiology and effects of GERD, and provide information on the clinical approach to this common disorder.
... In a study in which the effect of raising the head of the bed in patients with nocturnal reflux symptoms was investigated, a significant decrease was found in reflux time, determined in the supine position, acid clearance time, and the quantity of reflux lasting longer than 5 minutes in 24 patients whose bed head position was elevated 20 cm with a 20 cm block for 6 days (19). In the study of Johnson and DeMeester (20), an improvement of 67% was observed in acid clearance time in patients sleeping with an elevated bed head position (p<0.025). ...
Lifestyle modification has an important role in the treatment of gastroesophageal reflux disease (GERD). The development
of GERD symptoms with various foods shows individual differences. Although there is not enough
evidence that certain substances in a diet could lead to GERD symptoms, the literature suggests that there
might be a relationship between reflux development and salt, salted foods, chocolate, fatty foods, and fizzy
drinks. Because lying on the left side and raising the head of the bed in a supine position reduces the development
of nocturnal reflux symptoms, the head should be elevated for patients with reflux symptoms at night,
and the patient should lie on the left side. Smoking and obesity (especially abdominal) trigger GERD symptoms.
Whereas excessive physical activity is a significant risk factor for the development of GERD, regular and mildmoderate
physical activity has been shown to reduce the symptoms of reflux.
... This is mainly because changes to diet and lifestyle have been shown to alleviate symptoms and reduce the chance of recurrence. For example, acid regurgitation is reduced greatly by sleeping with the head in an elevated position (Khan et al., 2012). The interventions of lifestyle, eating habits, exercise, and psychology plus acupuncture have a synergetic effect on drug treatment, promotion of therapeutic effects, adherence, and alleviation of symptoms ( Haruma et al., 2015 ;Maradey-Romero, Kale, & Fass, 2014 ). ...
Gastroesophageal reflux disease is a chronic disease with a high incidence worldwide. The various symptoms have substantial impact on the quality of life of affected individuals. A long-term self-management program can increase the ability of patients to make behavioral changes, and health outcomes can improve as a consequence. This study's aim was to evaluate the effectiveness of a self-management program for gastroesophageal reflux disease. A total of 115 patients with gastroesophageal reflux disease were allocated to the experimental group and the control group. The former received self-management intervention along with conventional drug therapy, whereas the latter received standard outpatient care and conventional drug therapy. After the clinical trial, the control group also received the same self-management intervention. The levels of self-management behaviors, self-efficacy, gastroesophageal reflux disease symptoms, and psychological condition were compared. Those in the experimental group demonstrated significantly higher self-efficacy for managing their illness, showed positive changes in self-management behaviors, and had comparatively better remission of symptoms and improvement in psychological distress. The program helped patients with gastroesophageal reflux disease self-manage their illness as possible.
Background and objective:
Gastroesophageal reflux disease (GERD)-associated cough is defined as a special GERD with a predominant cough symptom and is a common cause of chronic cough. This review summarizes our current understanding on the pathogenesis and management of GERD-associated cough.
Methods:
Main literatures on the pathogenesis and management of GERD-associated cough were reviewed and our understandings derived from the published studies were showed then.
Key content and findings:
Although esophageal-tracheobronchial reflex mainly underlies the pathogenesis of GERD-associated cough, its counterpart-tracheobronchial-esophageal reflex might exist and initiate the cough due to reflux induced by upper respiratory tract infection through the signaling of transient receptor potential vanilloid 1 linking airway and esophagus. The presence of reflux-associated symptoms such as regurgitation and heartburn along with coughing suggests an association between cough and GERD, which is supported by the objective evidence of abnormal reflux as detected by reflux monitoring. Although there is no general consensus, esophageal reflux monitoring provides the main diagnostic criteria for GERD-associated cough. Despite that acid exposure time and symptom associated probability are useful and mostly employed reflux diagnostic criteria, they are imperfect and far from being the gold standard. Acid suppressive therapy has long been recommended as the first choice for GERD-associated cough. However, the overall benefits of proton pump inhibitors have been controversial and need to be further assessed, especially in patients with cough due to non-acid reflux. Neuromodulators have demonstrated potential therapeutic effects for refractory GERD-associated cough, for which anti-reflux surgery may also be a promising treatment option.
Conclusions:
Tracheobronchial-esophageal reflex might initiate reflux-induced cough provoked by the upper respiratory tract infection. It is necessary to optimize the current standards and to explore new criteria with higher diagnostic potency. Acid suppressive therapy is the first choice for GERD-associated cough, followed by neuromodulators and anti-reflux surgery for refractory GERD-associated cough.
Patients with chronic cough experience major alteration in their quality of life. Given its numerous etiologies and treatments, this disease is a complex entity. To help clinicians involved in patient management of patients, guidelines have been issued by a group of French experts. They address definitions of chronic cough and initial management of patients with this pathology. We present herein the second-line tests that might be considered in patients whose coughing has persisted, notwithstanding initial management. The experts have also put forward a definition of unexplained or refractory chronic cough (URCC), the objective being to more precisely identify those patients whose cough persists despite optimal management. Lastly, these guidelines indicate the pharmacological and non-pharmacological interventions of use in URCC. Amitriptyline, pregabalin, gabapentin or morphine combined with speech and/or physical therapy are mainstays in treatment strategies. Other treatment options, such as P2X3 antagonists, are being developed and have generated high hopes among physicians and patients alike.
Description:
The purpose of this American Gastroenterological Association (AGA) Institute Clinical Practice Update is to review the available evidence and expert advice regarding the clinical management of patients with suspected extraesophageal gastroesophageal reflux disease.
Methods:
This article provides practical advice based on the available published evidence including that identified from recently published reviews from leading investigators in the field, prospective and population studies, clinical trials, and recent clinical guidelines and technical reviews. This best practice document is not based on a formal systematic review. The best practice advice as presented in this document applies to patients with symptoms or conditions suspected to be related to extraesophageal reflux (EER). This expert review was commissioned and approved by the AGA Institute Clinical Practice Updates Committee (CPUC) and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership and underwent internal peer review by the CPUC and external peer review through standard procedures of Clinical Gastroenterology and Hepatology. These Best Practice Advice (BPA) statements were drawn from a review of the published literature and from expert opinion. Because systematic reviews were not performed, these BPA statements do not carry formal ratings of the quality of evidence or strength of the presented considerations. BEST PRACTICE ADVICE 1: Gastroenterologists should be aware of potential extraesophageal manifestations of gastroesophageal reflux disease (GERD) and should inquire about such disorders including laryngitis, chronic cough, asthma, and dental erosions in GERD patients to determine whether GERD may be a contributing factor to these conditions. BEST PRACTICE ADVICE 2: Development of a multidisciplinary approach to extraesophageal (EER) manifestations is an important consideration because the conditions are often multifactorial, requiring input from non-gastroenterology (GI) specialties. Results from diagnostic testing (ie, bronchoscopy, thoracic imaging, laryngoscopy, etc) from non-GI disciplines should be taken into consideration when gastroesophageal reflux (GER) is considered as a cause for extraesophageal symptoms. BEST PRACTICE ADVICE 3: Currently, there is no single diagnostic tool that can conclusively identify GER as the cause of EER symptoms. Determination of the contribution of GER to EER symptoms should be based on the global clinical impression derived from patients' symptoms, response to GER therapy, and results of endoscopy and reflux testing. BEST PRACTICE ADVICE 4: Consideration should be given toward diagnostic testing for reflux before initiation of proton pump inhibitor (PPI) therapy in patients with potential extraesophageal manifestations of GERD, but without typical GERD symptoms. Initial single-dose PPI trial, titrating up to twice daily in those with typical GERD symptoms, is reasonable. BEST PRACTICE ADVICE 5: Symptom improvement of EER manifestations while on PPI therapy may result from mechanisms of action other than acid suppression and should not be regarded as confirmation for GERD. BEST PRACTICE ADVICE 6: In patients with suspected extraesophageal manifestation of GERD who have failed one trial (up to 12 weeks) of PPI therapy, one should consider objective testing for pathologic GER, because additional trials of different PPIs are low yield. BEST PRACTICE ADVICE 7: Initial testing to evaluate for reflux should be tailored to patients' clinical presentation and can include upper endoscopy and ambulatory reflux monitoring studies of acid suppressive therapy. BEST PRACTICE ADVICE 8: Testing can be considered for those with an established objective diagnosis of GERD who do not respond to high doses of acid suppression. Testing can include pH-impedance monitoring while on acid suppression to evaluate the role of ongoing acid or non-acid reflux. BEST PRACTICE ADVICE 9: Alternative treatment methods to acid suppressive therapy (eg, lifestyle modifications, alginate-containing antacids, external upper esophageal sphincter compression device, cognitive-behavioral therapy, neuromodulators) may serve a role in management of EER symptoms. BEST PRACTICE ADVICE 10: Shared decision-making should be performed before referral for anti-reflux surgery for EER when the patient has clear, objectively defined evidence of GERD. However, a lack of response to PPI therapy predicts lack of response to anti-reflux surgery and should be incorporated into the decision process.
Patients with chronic cough experience a high alteration of quality of life. Moreover, chronic cough is a complex entity with numerous etiologies and treatments. In order to help clinicians involved in the management of patients with chronic cough, guidelines on chronic cough have been established by a group of French experts. These guidelines address the definitions of chronic cough and the initial management of patients with chronic cough. We present herein second-line tests that might be considered in patients with cough persistence despite initial management. Experts also propose a definition of unexplained or refractory chronic cough (URCC) in order to better identify patients whose cough persists despite optimal management. Finally, these guidelines address the pharmacological and non-pharmacological interventions useful in URCC. Thus, amitryptilline, pregabalin, gabapentin or morphine combined with speech and/or physical therapy are a mainstay of treatment strategies in URCC. Other treatment options, such as P2 × 3 antagonists, are being developed.
Gastroesophageal reflux treatment varies greatly across the pediatric age spectrum. Infant reflux treatments rely heavily on nutritional interventions, whereas reflux in older children is treated more commonly with medications. However, because of the broad differential diagnosis, treatment nonresponse merits a re-evaluation of the diagnosis being treated and additional testing to provide a more precision-medicine approach to care.
The diagnosis and management of gastroesophageal reflux disease (GERD) in patients with obesity is similar to patients without obesity, and weight loss has been shown to improve GERD. Medical obesity therapies, such as antiobesity pharmacotherapy, and bariatric surgery are unique treatment considerations in patients with obesity presenting with GERD symptoms. The initial management of GERD is centered around conservative therapeutic options. Counseling patients about diet, lifestyle changes, and pharmacotherapy are important aspects in managing GERD. The goal of treatment is symptomatic relief and the prevention of complications such as esophageal adenocarcinoma, which occurs more commonly in patients with obesity.
Gastroesophageal reflux disease (GERD) and its complications such as esophagitis, Barrett’s esophagus, and esophageal adenocarcinoma are more prevalent in the elderly compared to the young. This is likely due to the higher prevalence of risk factors and hyposensitivity to symptoms in this age group, which makes diagnosis and treatment more challenging. In this chapter we focus on the epidemiology, etiopathogenesis, diagnosis, and management (medical and surgical) of GERD and its complications in the elderly. Diagnosis of GERD is made by a combination of clinical features (identification of risk factors and esophageal and extraesophageal symptoms) and investigations (such as ambulatory pH monitoring and endoscopy). The mainstay of treatment is a combination of lifestyle modifications and medications (predominantly proton pump inhibitors and histamine receptor antagonists). Surgery is usually reserved for those with refractory symptoms and complications not responding to medications. We also address some of the current misconceptions on the adverse effects attributed to proton pump inhibitors in the literature and provide recommendations on their appropriate and judicious use.
Gastroesophageal reflux is closely associated with cough and is a common etiology of chronic cough. Cough due to reflux can be elicited by acidic and non-acidic reflux, and its assessment and diagnosis are a process to establish a cause–effect relation between reflux and cough, with esophageal impedance–pH monitoring as a gold standard for the detection of abnormal reflux. The favorable response to anti-reflux treatment is a key step to confirm reflux as the cause of chronic cough. In addition to lifestyle modification, pharmacological anti-reflux therapy is a first-line choice, and anti-reflux surgery is a promising option for cure.
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.
Background
The clinical impact of head-of-bed elevation in patients with gastro-oesophageal reflux disease is unclear, because of inconsistency and methodological limitations of previous studies.
Patients and methods
A randomised single-blind single-centre controlled clinical trial with a 2 × 2 cross-over design, in 39 pharmacologically treated patients with gastro-oesophageal reflux disease. Active intervention was to use a head-of-bed-elevation of 20 cm for 6 weeks and then to sleep without inclination for 6 additional weeks, with a wash-out of 2 weeks between periods. The primary outcome was a change ≥10% in RDQ score and secondary outcomes were a change ≥10% in SF-36 score, patient preference and frequency of adverse events.
Results
27 (69.2%) patients who used the intervention reached the primary outcome vs 13 (33.3%) patients in the control group (RR: 2.08; 95% CI: 1.19–3.61). No effect was found in SF-36 score (RR: 1.11; 95% CI: 0.47–2.60). Preference favouring the intervention was 77.1% and adverse event proportion was 54.0%.
Conclusion
Head-of-bed elevation improved reflux symptoms but there was no effect on quality of life. The finding of a non-optimal risk-benefit ratio warrants additional studies before this intervention can be recommended (IBELGA, ClinicalTrials.gov identifier NCT02706938).
Resumen
Introducción
El impacto clínico de la elevación de la cabecera de la cama en pacientes con enfermedad por reflujo gastroesofágico es incierto, por inconsistencia y limitaciones metodológicas en estudios previos.
Pacientes y métodos
Ensayo clínico controlado aleatorizado unicéntrico simple-ciego cruzado 2x2, en 39 pacientes con enfermedad por reflujo gastroesofágico tratados farmacológicamente. La intervención fue elevar la cabecera de la cama a 20 cm de altura durante 6 semanas y luego a dormir sin inclinación otras 6 semanas, con un lavado de 2 semanas entre períodos. El desenlace primario fue el cambio ≥ 10% de la puntuación RDQ y los desenlaces secundarios fueron el cambio ≥ 10% de la puntuación SF-36, preferencia del paciente y frecuencia de eventos adversos.
Resultados
27 (69,2%) pacientes que utilizaron la intervención cumplieron el desenlace primario, vs. 13 (33,3%) pacientes en el grupo control (RR: 2,08; IC95%: 1,19 - 3,61). No se encontró efecto en la puntuación SF-36 (RR: 1,11; IC95%: 0,47 - 2,60). La preferencia por la intervención fue del 77,1% y la proporción de eventos adversos fue del 54,0%.
Conclusión
La elevación de la cabecera de la cama redujo los síntomas de reflujo, pero no tuvo efecto en la calidad de vida. Por un balance riesgo-beneficio no óptimo, se requieren estudios adicionales antes de recomendar esta intervención (IBELGA, identificador ClinicalTrials.gov NCT02706938).
Background:
Studies revealed the symptom of gastroesophageal reflux (GE reflux) disturb patients following esophageal reconstruction.
Objective:
To examine the effect of head-of-bed elevation by using the wedge-shaped pillow (WSP) on the reflux symptoms of patients with esophageal cancer following esophagectomy and reconstruction.
Methods:
Fourteen patients with nocturnal reflux symptoms following esophagectomy and gastric tube reconstruction were enrolled and randomized into 2 groups. A 2-week crossover trial was performed using 2 sequences (drug only and drug plus WSP). The WSP was designed with a height of 20 cm, a length of 62 cm, and an elevation angle of 20 degrees and used with fabricated from memory foam. After 2 weeks, all of the patients received combined drug and WSP intervention for 3 months. Reflux symptoms were measured by Dysfunction After Upper Gastrointestinal Surgery for Cancer and examined by endoscopic observations prior to intervention and follow-up for 3 months.
Result:
The average reflux symptom score for the combined drug and WSP treatment in the beginning 2 weeks was lower than that for the drug-only sequence. The severity of esophagitis was improved in 46.1%, and 38.5% showed a stabilization after 3 months.
Conclusions:
Combined drug and WSP treatment may be beneficial in improving GE reflux symptoms.
Implications for practice:
Nursing care professionals would suggest patients find a similar WSP to elevate the head of the bed to reduce the severity of nocturnal reflux symptoms after esophagectomy and gastric tube reconstruction.
Aim:
Postural measures are frequently recommended for gastroesophageal reflux (GER) symptoms, despite limited evidence. This was the first study to assess the impact of upright and recumbent body positions on GER episodes in children and adolescents, not just infants.
Methods:
We retrospectively assessed the pH-impedance parameters of paediatric patients referred for possible GER-related symptoms to two hospitals in Naples and Rome, Italy, from September 2016 to September 2018. Data were separately obtained for the time that the patients spent in upright and recumbent positions.
Results:
Data from 187 patients under the age of 18 were collected, at a mean age of just over seven years. We found that the acid exposure time was stable irrespective of changes in body position (p>0.05). The mean number of reflux episodes per hour was 2.99 during the upright position and 1.21 during the recumbent position (p<0.05) and the mean oesophageal acid clearance time was 44.4 and 93.4 seconds, respectively (p<0.05).
Conclusion:
Most paediatric patients experienced reflux in the upright rather than recumbent position, probably as a result of frequent transient lower oesophageal sphincter relaxations while they were awake. In particular, our findings provide new insights on postural measures for reflux in children and adolescents.
Laryngopharyngeal reflux (LPR) is commonly diagnosed by otolaryngologists and may be managed using various approaches. Traditionally, otolaryngologists treat LPR with a combination of medications and lifestyle modifications. These lifestyle changes are often the same as those provided for patients with gastroesophageal reflux disease (GERD), commonly referred to as acid reflux. While pharmacological therapy for LPR is well studied, there is a paucity of data on the effect of lifestyle modifications for treating LPR. Most studies are found in the gastroenterology literature and address esophageal rather than laryngopharyngeal symptoms. In this chapter, we will explore lifestyle and dietary modifications and their rationale for patients with laryngopharyngeal reflux and will discuss the evidence where available.
Gastroesophageal reflux disease (GORD) is a chronic disorder that is caused by abnormal reflux. It is associated with prolonged exposure of the distal oesophagus and extra oesophageal airways to gastric contents and leads to cardinal symptoms and/or findings, which affect patient quality of life [1]. Typical GORD symptoms include heartburn (usually defined as a rising retrosternal burning discomfort) and/or regurgitation, and atypical symptoms include laryngopharyngeal and pulmonary symptoms, such as cough and non-cardiac chest pain (Fig. 2.1) [2].
Gastro-oesophageal reflux disease (GORD) is a common comorbidity in bronchiectasis, and is often associated with poorer outcomes. The cause and effect relationship between GORD and bronchiectasis has not yet been fully elucidated and a greater understanding of the pathophysiology of the interaction and potential therapies is required. This review explores the underlying pathophysiology of GORD, its clinical presentation, risk factors, commonly applied diagnostic tools, and a detailed synthesis of original articles evaluating the prevalence of GORD, its influence on disease severity and current management strategies within the context of bronchiectasis. The prevalence of GORD in bronchiectasis ranges from 26% to 75%. Patients with co-existing bronchiectasis and GORD were found to have an increased mortality and increased bronchiectasis severity, manifest by increased symptoms, exacerbations, hospitalisations, radiological extent and chronic infection, with reduced pulmonary function and quality of life. The pathogenic role of Helicobacter pylori infection in bronchiectasis, perhaps via aspiration of gastric contents, also warrants further investigation. Our index of suspicion for GORD should remain high across the spectrum of disease severity in bronchiectasis. Identifying GORD in bronchiectasis patients may have important therapeutic and prognostic implications, although clinical trial evidence that treatment targeted at GORD can improve outcomes in bronchiectasis is currently lacking.
Gastroesophageal reflux is a normal physiologic process, with multiple mechanisms in place to prevent physiologic reflux from becoming pathologic. One such mechanism is esophageal clearance. Esophageal clearance is composed of two distinct phases: volume clearance and chemical clearance. Volume clearance utilizes swallowing and esophageal peristalsis to empty the esophagus of reflux bolus and virtually all acid. Chemical clearance neutralizes the residual acid film by saliva, either swallowed or secreted by the esophagus. Combined pH-multichannel intraluminal impedance is the best technique to measure both phases of clearance. Normal values for children have been established. If either phase of esophageal clearance is prolonged, the esophagus experiences increased acid exposure, and this can result in secondary complications. There are physiologic and disease states which can impact either or both of the clearance phases. They do so by impacting the swallow, esophageal peristalsis, esophageal motility, and composition or quantity of saliva. As a result, these patients are predisposed to gastroesophageal reflux disease.
Objective
Laryngopharyngeal reflux (LPR) symptoms are often resistant to management and cause significant quality of life impairment to patients with this disease. This study assesses the utility of a sleep-positioning device (SPD) in treating LPR.
Design
Single center prospective cohort study.
Setting
Tertiary medical center
Participants
27 adult patients with diagnosed laryngopharyngeal reflux.
Intervention
An SPD consisting of a two-component wedge-shaped base pillow and a lateral positioning body pillow (Medcline, Amenity Health Inc.) was given to patients with a diagnosis of LPR. Subjects slept using the device for at least 6 h per night for 28 consecutive nights.
Main outcomes
Primary outcomes were Nocturnal Gastroesophageal Reflux Symptom Severity and Impact Questionnaire (N-GSSIQ) and the Reflux Symptoms Index (RSI) survey instrument. Each was collected at baseline, after 14, and after 28 days of SPD use.
Results
27 patients (19 female and 8 male; age 57.1 ± 12.8, BMI 29.0 ± 8.1) were recruited. At baseline mean N-GSSIQ was 50.1 ± 22.4 and mean RSI of 29.6 ± 7.7. Repeated measure analysis showed that subjects' total N-GSSIQ scores decreased by an average of 19.1 (p = 0.0004) points by two weeks and 26.5 points by 4 weeks (p < 0.0001). RSI decreased an average of 5.3 points by 2 weeks (p = 0.0425) and an average of 14.0 points by 4 weeks (p < 0.0001).
Conclusions
In patients with LPR, SPD treatment significantly improves self-reported symptoms of nocturnal reflux as well as symptoms specific to LPR. These results support the therapeutic efficacy of a SPD for patients with LPR.
Conclusions: It is considered that a regimen combining pharmacologic management and lifestyle modifications is the most effective treatment for laryngeal granulomas caused by GER.
Objectives: This study compared the results of the combination therapy and surgery to determine the best treatment of laryngeal granuloma caused by gastro-esophageal reflux in 51 patients.
Methods: Prospective study.
Results: In the conservative treatment group, the CR rate was 89.7% and recurrence rate was 2.6%, while the lesions remained in patients (7.7%). This study compared the CR and recurrence rates between conservative treatment and surgery for granuloma. The results showed that the laryngeal granuloma recurrence rate was significantly lower with the conservative treatment regimen compared with surgery (p = .0016).
The aim of this study was to measure the efficacy of a positional therapy device (PTD) at reducing proton pump inhibitor (PPI) refractory nocturnal GERD symptoms. Among patients with GERD, nocturnal symptoms are very common. A recent study demonstrated a decrease in nocturnal acid exposure and reflux episodes in healthy volunteers who slept using a PTD. This is a single-center prospective trial involving patients on anti-secretory medications with continued nocturnal heartburn and regurgitation. Patients completed the Nocturnal GERD Symptom Severity and Impact Questionnaire (N-GSSIQ) and GERD health-related quality of life questionnaire (GERD-HRQL) at enrollment. Patients were instructed to sleep on the PTD for at least 6 hours a night during the two week study period; subjects continued their baseline anti-secretory medication dose. After 2 weeks, the questionnaires were repeated. A total of 27 patients (16 females and 11 males; age 57.8 ± 15.1) were recruited. After 2 weeks of PTD use, N-GSSIQ scores significantly improved from baseline, with a mean total score improvement of 39.5 (mean 57.7 [pre] vs. 18.2 [post], P < 0.001). Significant improvement from baseline was also observed for the GERD-HRQL questionnaire (29.8 vs. 16.7, P < 0.001). No adverse events were reported. At 3 months after the trial period, 91% of the subjects continued to use the PTD on a nightly basis. Use of the PTD significantly decreased nocturnal GERD symptoms and improved GERD-HRQL. The PTD was well tolerated during the study period and for 3 months after enrollment.
Background:
We updated the 2006 ACCP clinical practice guidelines for management of reflux-cough syndrome.
Methods:
Two PICO questions were addressed by systematic review: 1) can therapy for gastroesophageal reflux improve or eliminate cough in adults with chronic and persistently troublesome cough? and 2) are there minimal clinical criteria to guide practice in determining that chronic cough is likely to respond to therapy for gastroesophageal reflux?
Results:
We found no high quality studies pertinent to either question. From available RCTs addressing question #1, we concluded that: 1) there was a strong placebo effect for cough improvement; 2) studies including diet modification and weight loss had better cough outcomes; 3) while lifestyle modifications and weight reduction may be beneficial in suspected reflux-cough syndrome, PPIs demonstrated no benefit when used in isolation; and 4) because of potential carryover effect, crossover studies using PPIs should be avoided. For question #2, we concluded from the available observational trials that: 1) an algorithmic approach to management resolved chronic cough in 82-100% of instances; 2) cough variant asthma and upper airway cough syndrome (UACS) from rhinosinus conditions were the most commonly reported etiologies; and 3) the reported prevalence of reflux-cough syndrome varied widely.
Conclusions:
The panelists: 1) endorsed use of a diagnostic/therapeutic algorithm addressing common cough etiologies including symptomatic reflux, 2) advised that while lifestyle modifications and weight reduction may be beneficial in suspected reflux-cough syndrome, PPIs demonstrated no benefit when used in isolation, and 3) suggested that physiological testing be reserved for refractory patients being considered for anti-reflux surgery or in whom there is strong clinical suspicion warranting diagnostic testing.
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
Ambulatory 24-h esophageal pH monitoring is increasing in popularity as the means to measure esophageal exposure to gastric juice and document the presence of gastroesophageal reflux disease, particularly before surgical therapy. Normal values for pH exposure were obtained from 50 asymptomatic healthy subjects. Receiver operating characteristic curves constructed from another 25 asymptomatic healthy subjects and 25 selected patients with other markers of increased esophageal acid exposure showed that a composite score and the percent total time pH less than 4 provide the most efficient interpretation of the test with a sensitivity of 96%, a specificity of 100% and an accuracy of 98% for the composite score, and a sensitivity, specificity, and accuracy of 96% for the percent total time pH less than 4. Repeat monitoring of healthy volunteers and symptomatic subjects in the inpatient and outpatient environment showed no significant difference, with the exception that the number of reflux episodes was significantly greater during the outpatient recording in volunteers. This did not affect the clinical accuracy of the test. Esophageal pH probes were well tolerated, but caused belching and coughing during the early part of the monitored period. We conclude that computerized ambulatory 24-h esophageal pH monitoring in the outpatient setting provides accurate and reproducible results.
Oesophageal manometry and 24 hour ambulatory pH recordings from the distal oesophagus were carried out in 25 patients with complications of oesophagitis (stricture, Barrett's oesophagus or oesophageal ulcer) and compared with 25 patients with uncomplicated oesophagitis. Acid reflux was more severe in the complicated group with 26.2% of time below pH 4 compared with 11.3% in uncomplicated patients (p less than 0.01). This difference was most marked at night, when complicated patients had long periods of acid reflux with 35.6% time less than pH 4 compared with 5.2% uncomplicated (p less than 0.001). The mean duration of nocturnal acid reflux was 15.4 minutes (2.1 minutes uncomplicated, p less than 0.001). Oesophageal motility was markedly abnormal in all groups, but with no demonstrable differences in lower oesophageal sphincter pressure or peristalsis between the groups. Patients with complications of oesophagitis have different patterns of acid reflux from uncomplicated patients, with prolonged nocturnal bathing of the oesophageal mucosa, which may be the cause of stricture formation, metaplasia, or ulceration.
We studied clearance of acid from the esophagus and esophageal emptying in normal subjects. A 15-ml bolus of 0.1 N hydrochloric acid (pH 1.2) radiolabeled with [99mTc]sulfur colloid was injected into the esophagus, and the subject swallowed every 30 seconds. Concurrent manometry and radionuclide imaging showed nearly complete emptying of acid from the esophagus by an immediate secondary peristaltic sequence, although esophageal pH did not rise until the first swallow 30 seconds later. Esophageal pH then returned to normal by a series of step increases, each associated with a swallow-induced peristaltic sequence. Saliva stimulation by an oral lozenge shortened the time required for acid clearance, whereas aspiration of saliva from the mouth abolished acid clearance. Saliva stimulation or aspiration did not affect the virtually complete emptying of acid volume by the initial peristaltic sequence. We conclude that esophageal acid clearance normally occurs as a two-step process: (1) Virtually all acid volume is emptied from the esophagus by one or two peristaltic sequences, leaving a minimal residual amount that sustains a low pH, and (2) residual acid is neutralized by swallowed saliva.
Endoscopic oesophageal changes are diagnostically helpful and identify patients exposed to the risk of disease chronicity. However, there is a serious lack of agreement about how to describe and classify the appearance of reflux oesophagitis
To examine the reliability of criteria that describe the circumferential extent of mucosal breaks and to evaluate the functional and clinical correlates of patients with reflux disease whose oesophagitis was graded according to the Los Angeles system.
Forty six endoscopists from different countries used a detailed worksheet to evaluate endoscopic video recordings from 22 patients with the full range of severity of reflux oesophagitis. In separate studies, Los Angeles system gradings were correlated with 24 hour oesophageal pH monitoring (178 patients), and with clinical trials of omeprazole treatment (277 patients).
Evaluation of circumferential extent of oesophagitis by the criterion of whether mucosal breaks extended between the tops of mucosal folds, gave acceptable agreement (mean kappa value 0.4) among observers. This approach is used in the Los Angeles system. An alternative approach of grouping the circumferential extent of mucosal breaks as occupying 0-25%, 26-50%, 51-75%, 76-99%, or 100% of the oesophageal circumference, gave unacceptably high interobserver variation (mean kappa values 0-0.15) for all but the lowest category of extent (mean kappa value 0.4). Severity of oesophageal acid exposure was significantly (p<0.001) related to the severity grade of oesophagitis. Preteatment oesophagitis grades A-C were related to heartburn severity (p<0.01), outcomes of omeprazole (10 mg daily) treatment (p<0.01), and the risk for symptom relapse off therapy over six months (p<0.05).
Results add further support to previous studies for the clinical utility of the Los Angeles system for endoscopic grading of oesophagitis.
Lifestyle modifications are first-line therapy for patients with gastroesophageal reflux disease (GERD). We applied an evidence-based approach to determine the efficacy of lifestyle measures for GERD management. We used PubMed and Ovid to perform a search of the literature published between 1975 and 2004 using the key words heartburn, GERD, smoking, alcohol, obesity, weight loss, caffeine or coffee, citrus, chocolate, spicy food, head of bed elevation, and late-evening meal. Each study was reviewed by 2 reviewers who assigned one of the following ratings: evidence A, randomized clinical trials; evidence B, cohort or case-control studies; evidence C, case reports or flawed clinical trials; evidence D, investigator experience; or evidence E, insufficient information. We screened 2039 studies and identified 100 that were relevant. Only 16 clinical trials examined the impact on GERD (by change in symptoms, esophageal pH variables, or lower esophageal sphincter pressure) of the lifestyle measure. Although there was physiologic evidence that exposure to tobacco, alcohol, chocolate, and high-fat meals decreases lower esophageal sphincter pressure, there was no published evidence of the efficacy of dietary measures. Neither tobacco nor alcohol cessation was associated with improvement in esophageal pH profiles or symptoms (evidence B). Head of bed elevation and left lateral decubitus position improved the overall time that the esophageal pH was less than 4.0 (evidence B). Weight loss improved pH profiles and symptoms (evidence B). Weight loss and head of bed elevation are effective lifestyle interventions for GERD. There is no evidence supporting an improvement in GERD measures after cessation of tobacco, alcohol, or other dietary interventions.
In a randomized multicentric trial the effect of sleeping with the bed-head raised was studied in inpatients with reflux symptoms. All patients underwent an endoscopic and pH-metric examination. As a result from the diagnostic procedures three groups were formed: group 1 - refluxlike dyspepsia (endoscopic and pH-metric examination normal), group 2 - reflux disease without esophagitis (endoscopy normal, pH-metric examination abnormal), group 3 - refluxesophagitis (endoscopy abnormal). All patients were randomly assigned to either sleeping with horizontal bed-head or having the bed-head raised (15 cm). Furthermore, the patients in group 3 were put on treatment with omeprazole (20 mg twice a day) those in group 2 were treated with a procinetic drug (cisapride 30 mg). The patients in group 1 had no drug therapy. However, antacids were allowed in all patients. For a two-week-period reflux symptoms and use of antacids were registered. No difference was seen in the symptom-score or use of antacids. Also sub-group analysis (sex, age, body-mass-index, severity of esophagitis and nocturnal reflux) did not reveal any impact of sleeping with the bed-head raised on reflux symptoms or use of antacids.
Continuous oesophageal pH measurements have been used to assess the influence of posture (lying, sitting, bed-up) on gastro-oesophageal reflux. The percentage of time during which oesophageal pH was below 5 and the number of reflux episodes was significantly reduced when patients were in bed-up position than when sitting or lying. There was no significant difference when sitting and lying positions were compared. The results suggest that by adopting the bed-up position (elevation of the head end of the bed with blocks of 28 cm), the patient will have a symptomatic benefit, the frequency of reflux is decreased, and acid clearing is improved.
Esophageal acid clearing in normal subjects was studied in different body positions, with an assessment of reproducibility, after dry and water swallows, after smoking, and after alcohol intake. A significant increase in the number of swallows to raise the distal esophageal pH to 5.0 was found in the head-down position (p less than 0.003), after smoking (p less than 0.003), and after alcohol intake (p less than 0.001). It is proposed that the outcome of the acid-clearing test reflects both the transporting capacity of the esophageal muscles and the production of saliva. The precision of the acid-clearing test is not satisfactory, which makes it unsuitable for use in individual cases. It seems, however, well fitted for evaluation of esophageal acid clearing in larger samples.
Fiberoptic laryngoscopic examinations were performed on 40 patients with gastroesophageal reflux disease, 25 of whom had persistent laryngeal symptoms (dysphonia, cough, globus sensation, frequent throat clearing, or sore throat) and 15 without laryngeal symptoms who served as disease controls. Ten patients with laryngeal symptoms but none of the controls had laryngoscopic findings consistent with reflux laryngitis. Dual-site ambulatory pH recordings were obtained with the pH electrodes spaced 15 cm apart and with the proximal sensor positioned just distal to the upper esophageal sphincter. Patients in the three groups (disease controls: group 1; patients with symptoms but without laryngoscopic findings: group 2; and patients with both laryngeal symptoms and findings: group 3) were comparable in terms of age, smoking habit, the presence of esophagitis, and distal esophageal acid exposure. Proximal esophageal acid exposure was, however, significantly increased in groups 2 and 3, and nocturnal proximal esophageal acidification occurred in over half of these patients but in none of the group 1 patients. We conclude that the subset of reflux patients who experience laryngeal symptoms show significantly more proximal esophageal acid exposure (especially nocturnally) and often have laryngoscopic findings of posterior laryngitis not observed in control reflux patients.
Sleeping with the bed-head raised is commonly recommended as treatment for patients with troublesome oesophagitis, but its effect has not been objectively tested. Ranitidine therapy is useful in oesophagitis, but it does not often produce complete relief of symptoms. The effects of each of these treatments alone and in combination have been studied in 71 patients with severe (grade III) peptic oesophagitis. Each treatment improved both symptoms and endoscopic appearances significantly more than placebo did. However, the combination of the two treatments was much better than either alone; the reduction in pain score and the area of ulceration healed were about twice those with either treatment alone. Smoking more than five cigarettes per day or drinking more than 30 g alcohol per day significantly reduced the effectiveness of ranitidine therapy, but age, sex, body weight, or the presence of a hiatus hernia had no detectable effect.
In a randomized crossover study, we compared the effect on gastroesophageal reflux of three sleeping positions: elevation of the head of the bed on standard eight-inch bed blocks; elevation by a foam wedge; or a flat position. Fifteen subjects with moderate to severe reflux symptoms were studied in each position on consecutive nights using continuous intraesophageal pH monitoring. We found no difference in reflux frequency among the positions. The wedge caused a statistically significant decrease in the time that distal esophageal pH was less than 4 as compared to the flat position. The wedge also decreased the longest episode experienced by the subjects. Elevation on blocks caused a similar improvement in parameters but failed in this study to achieve statistical significance. Both elevation by a wedge and on blocks showed a trend towards a decrease in clearance time as compared to the flat position. The patients did not always prefer elevation on a wedge, but for some it is a valuable alternative to elevation by bed blocks.
Normal people without symptoms of reflux do in fact reflux small quantities of acid into the oesophagus when either standing or sitting, but do not reflux acid when they are sleeping lying flat. This ;physiological' incompetence in the upright position is not of great importance in that the oesophagus is able to, and consistently does, deal with small concentrations of refluxed acid material. The oesophageal measurements of pH have a limited use as a diagnostic measure and may indicate acid reflux in the relaxed person not demonstrated by radiology.
In a randomized multicentric trial the effect of sleeping with the bed-head raised was studied in inpatients with reflux symptoms. All patients underwent an endoscopic and pH-metric examination. As a result from the diagnostic procedures three groups were formed: group 1 - refluxlike dyspepsia (endoscopic and pH-metric examination normal), group 2 - reflux disease without esophagitis (endoscopy normal, pH-metric examination abnormal), group 3 - refluxesophagitis (endoscopy abnormal). All patients were randomly assigned to either sleeping with horizontal bed-head or having the bed-head raised (15 cm). Furthermore, the patients in group 3 were put on treatment with omeprazole (20 mg twice a day) those in group 2 were treated with a procinetic drug (cisapride 30 mg). The patients in group 1 had no drug therapy. However, antacids were allowed in all patients. For a two-week-period reflux symptoms and use of antacids were registered. No difference was seen in the symptom-score or use of antacids. Also sub-group analysis (sex, age, body-mass-index, severity of esophagitis and nocturnal reflux) did not reveal any impact of sleeping with the bed-head raised on reflux symptoms or use of antacids.
Two types of reflux episodes have been identified: upright or daytime and supine or nocturnal. The population-based prevalence of symptoms of nocturnal gastroesophageal reflux disease (GERD) and the impact of those symptoms on health-related quality of life (HRQL) have not been established.
A national random-sample telephone survey was conducted to estimate the prevalence of frequent GERD and nocturnal GERD-like symptoms and to assess the relationship between HRQL, GERD, and nocturnal GERD symptoms. Respondents were classified as controls, subjects with symptomatic nonnocturnal GERD, and subjects with symptomatic nocturnal GERD. The HRQL was assessed using the Medical Outcomes Study Short-Form 36 Health Survey (SF-36).
The prevalence of frequent GERD was 14%, with an overall prevalence of nocturnal GERD of 10%. Seventy-four percent of those with frequent GERD symptoms reported nocturnal GERD symptoms. Subjects with nonnocturnal GERD had significant decrements on the SF-36 physical and mental component summary scores compared with the US general population. Subjects reporting nocturnal GERD symptoms were significantly more impaired than subjects reporting nonnocturnal GERD symptoms on both the physical component summary (38.94 vs 41. 52; P<.001) and mental component summary (46.78 vs 49.51; P<.001) and all 8 subscales of the SF-36 (P<.001). Subjects with nocturnal GERD demonstrated considerable impairment compared with the US general population and chronic disease populations. Subjects with nocturnal GERD had significantly more pain than those with hypertension and diabetes (P<.001) and similar pain compared with those with angina and congestive heart failure.
Nocturnal symptoms are commonly experienced by individuals who report frequent GERD symptoms. In addition, HRQL is significantly impaired in those persons who report frequent GERD symptoms, and HRQL impairment is exacerbated in those who report nocturnal GERD symptoms.
The impact of gastro-oesophageal reflux disease on work productivity has become increasingly important, as the symptoms of gastro-oesophageal reflux disease affect individuals in their productive years of life.
To assess the impact of gastro-oesophageal reflux disease on reduced work productivity and to identify the predictors of reduced productivity.
A sample of employed individuals reporting chronic heartburn was selected from US household mail survey respondents. Heartburn severity and frequency were recorded using a diary, and work productivity was assessed using the Work Productivity and Activity Impairment Questionnaire for Patients with Symptoms of Gastro-oesophageal Reflux Disease. Predictors of reduced productivity were evaluated.
Over 30% of heartburn sufferers reported reduced productivity. Individuals with symptoms of gastro-oesophageal reflux disease (n = 1003) reported 6.0% reduced productivity attributable to symptoms. Over 48% of respondents with severe symptoms reported reduced productivity, compared with 40% and 12% of respondents with moderate and mild symptoms, respectively. Using logistic regression, severity, a younger age and nocturnal symptoms were associated with increased odds of reduced productivity. In those reporting nocturnal heartburn, medication use and sleep interference increased the odds of reduced productivity.
Reduced work productivity is seen in a large proportion of subjects on prescription medication for gastro-oesophageal reflux disease. Symptom severity and nocturnal heartburn are significantly associated with reduced work productivity, particularly when nocturnal heartburn interferes with sleep.
The spectrum of gastro-oesophageal reflux disease (GERD) has expanded; indeed the majority of individuals with symptomatic GERD do not have erosive reflux disease (ERD); this group has been referred to as nonerosive or negative-endoscopy reflux disease (NERD). There may be important differences between NERD and ERD in terms of pathophysiology and management. Thus, NERD patients appear relatively resistant to proton pump inhibitors and may not be good surgical candidates. The clinician caring for patients with GERD must therefore be aware of the full spectrum of GERD and of the pathophysiological and therapeutic implications of NERD. Recent twin studies have revealed that genetic factors play a role in GERD and form the basis for future studies on the role of inheritance in the various manifestations of GERD. Several recent investigations have reaffirmed the primacy of acid reflux in the pathogenesis of GERD and have also provided insights into the pathophysiology of postprandial heartburn. Transient lower oesophageal sphincter relaxations and hiatal hernias have emerged as major and interacting factors in the genesis of reflux events and in the potentiation of acid exposure; the former are attracting considerable attention as a potential therapeutic target. Nocturnal acid breakthrough, which has been implicated in the failure of some patients to respond to high doses of proton pump inhibitors, appears, on further examination, to be a gastric rather than an oesophageal phenomenon, and may not be of clinical or therapeutic importance.
Gastro-oesophageal reflux disease (GERD) has been associated with a variety of supra-oesophageal symptoms, including asthma, laryngitis, hoarseness, chronic cough, frequent throat clearing and globus pharyngeus. GERD may be overlooked as the underlying mechanism for these symptoms because typical GERD symptoms may be absent, despite abnormal oesophageal acid exposure. Two basic mechanisms linking GERD with laryngeal symptoms have been proposed: direct contact of gastric acid with the upper airway, in some cases due to micro-aspiration, and a vagovagal reflex triggered by acidification of the distal portion of the oesophagus. Gastro-oesophageal reflux (GER) during sleep is believed to be an important mechanism for the development of supra-oesophageal complications of GERD, such as asthma and idiopathic pulmonary fibrosis (IPF). Several physiological changes during sleep, including prolonged oesophageal acid contact time, decreased upper oesophageal sphincter pressure, increased gastric acid secretion, decreased salivation, decreased swallowing and a decrease in conscious perception of acid, render an individual more susceptible to reflux-induced injury. Supra-oesophageal symptoms often improve in response to aggressive acid-suppressive therapy. However, many unanswered questions remain regarding the appropriate approach to diagnosis and treatment of patients with GERD-related supra-oesophageal symptoms. In this article we review the relationship between supra-oesophageal symptoms and GERD and, where possible, highlight the evidence supporting the role of night-time reflux as a contributing factor to these symptoms.
Heartburn is a symptom complex that has traditionally been accepted as an acid-mediated event and a reliable indicator of gastroesophageal reflux disease. Recently, however, these concepts have been questioned because patients with endoscopy-negative "heartburn" have lower response rates to acid suppression with proton pump inhibitors than do patients with endoscopy-positive "heartburn," ie, erosive esophagitis. As explanation for this, 3 different mechanisms have been proposed to explain the occurrence of heartburn in the endoscopy-negative setting. They are: esophageal visceral hypersensitivity, sustained esophageal contractions, and abnormal tissue resistance. In this report, we review the observations in support of each concept and propose a means for reconciling them under one hypothesis: abnormal tissue resistance. Essential to this review and to the conclusions drawn about the pathogenesis of heartburn in nonerosive reflux disease is a reaffirmation of the definition of reflux-associated "heartburn" as an acid-mediated event requiring "relief by antacids" as a necessary component of the history.
Sleep disturbances are common in patients with gastroesophageal reflux disease (GERD). This study examined the effects of esomeprazole on nighttime heartburn, GERD-related sleep disturbances, sleep quality, work productivity, and regular activities.
This multicenter, randomized, double-blind, placebo-controlled trial included adults with GERD-associated sleep disturbances and moderate-to-severe nighttime heartburn (recorded by patient diary during screening). Patients received oral esomeprazole 40 mg (n = 220) or 20 mg (n = 226) or placebo (n = 229) once daily for 4 wk. The primary outcome was relief of nighttime heartburn. Secondary outcomes included resolution of sleep disturbances, sleep quality measured by the Pittsburgh Sleep Quality Index (PSQI) questionnaire, and work productivity measured by the Work Productivity and Activity Impairment Questionnaire.
Nighttime heartburn was relieved in 53.1% (111/209), 50.5% (111/220), and 12.7% (28/221) of patients who received esomeprazole 40 mg, esomeprazole 20 mg, and placebo, respectively. Differences (95% CI) versus placebo were 40.5% (32.4%, 48.5%) and 37.8% (29.9%, 45.7%) and were highly significant (p < 0.0001). GERD-related sleep disturbances resolved in significantly more (p < 0.0001) patients who received esomeprazole 40 (73.7%) or 20 mg (73.2%) than in those who received placebo (41.2%). Both esomeprazole groups had greater PSQI global score changes from baseline (p < 0.0001 vs placebo) and more (p < 0.0001 vs placebo) work hours saved per week per patient compared with baseline (esomeprazole 40 mg, 11.6 h; esomeprazole 20 mg, 12.3 h; placebo, 6.2 h).
Esomeprazole reduced nighttime heartburn and GERD-related sleep disturbances and improved sleep quality and work productivity.
Review article: supra-oesophageal manifestations of gastro-oesophageal reflux disease and the role of night-time gastro-oesophageal reflux
- Fass