Article

Clinical trial: Acupuncture vs. doubling the proton pump inhibitor dose in refractory heartburn

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Abstract

The current standard of care in proton pump inhibitor failure is to double the proton pump inhibitor dose, despite limited therapeutic gain. Aims To determine the efficacy of adding acupuncture vs. doubling the proton pump inhibitor dose in gastro-oesophageal reflux disease patients who failed symptomatically on proton pump inhibitors once daily. Thirty patients with classic heartburn symptoms who continued to be symptomatic on standard-dose proton pump inhibitors were enrolled into the study. All participants underwent upper endoscopy while on proton pump inhibitors once daily. Subsequently, patients were randomized to either adding acupuncture to their proton pump inhibitor or doubling the proton pump inhibitor dose over a period of 4 weeks. Acupuncture was delivered twice a week by an expert. The two groups did not differ in demographic parameters. The acupuncture + proton pump inhibitor group demonstrated a significant decrease in the mean daytime heartburn, night-time heartburn and acid regurgitation scores at the end of treatment when compared with baseline, while the double-dose proton pump inhibitor group did not demonstrate a significant change in their clinical endpoints. Mean general health score was only significantly improved in the acupuncture + proton pump inhibitor group. Adding acupuncture is more effective than doubling the proton pump inhibitor dose in controlling gastro-oesophageal reflux disease-related symptoms in patients who failed standard-dose proton pump inhibitors.

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... For instance, adding acupuncture to Original paper standard-dose PPI reportedly achieved better results than doubling the PPI dose in patients who had failed standard-dose PPIs. 11 Since then, several other studies have investigated the effectiveness of acupuncture for GORD; however, no consensus has been reached. Moreover, to our knowledge, no systematic review or meta-analysis of trials of acupuncture for GORD has been conducted to date. ...
... The 12 articles included 11 journal papers 11 15-24 and one dissertation 25 with a total of 1235 patients (640 and 595 in the treatment and control groups, respectively). Among them, two studies (one conducted in the USA 11 applied MA/EA alone in the trial groups, while six studies 11 17 19 22-24 combined MA/EA with WM and one 16 included both types of comparison in view of its three-arm design, as described above. Detailed information is provided in table 1 and table S1 (see online supplementary material). ...
... Three studies 11 ...
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Background Gastro-oesophageal reflux disease (GORD) is one of the most common diseases presenting to gastroenterology clinics. Acupuncture is widely used as a complementary and alternative treatment for patients with GORD. Objective To explore the effectiveness of acupuncture for the treatment of GORD. Methods Four English and four Chinese databases were searched through June 2016. Randomised controlled trials investigating the effectiveness of manual acupuncture or electroacupuncture (MA/EA) for GORD versus or as an adjunct to Western medicine (WM) were selected. Data extraction and quality evaluation were performed by two authors independently and RevMan 5.2.0 was used to analyse data. Results A total of 12 trials involving 1235 patients were included. Meta-analyses demonstrated that patients receiving MA/EA combined with WM had a superior global symptom improvement compared with those receiving WM alone (relative risk (RR) 1.17, 95% CI 1.09 to 1.26; p=0.03; six studies) with no significant heterogeneity (I²=0%, p=0.41). Recurrence rates of those receiving MA/EA alone were lower than those receiving WM (RR 0.42,95% CI 0.29 to 0.61; p<0.001; three studies) with low heterogeneity (I²=7%, p=0.34), while global symptom improvement (six studies) and symptom scores (three studies) were similar (both p>0.05). Descriptive analyses suggested that acupuncture also improves quality of life in patients with GORD. Conclusion This meta-analysis suggests that acupuncture is an effective and safe treatment for GORD. However, due to the small sample size and poor methodological quality of the included trials, further studies are required to validate our conclusions. Trial registration number PROSPERO Systematic review registration no. CRD42016041916.
... Acupuncture has been proved to have a good effect for GERD. Adding acupuncture was more effective when compared with doubling the PPI dose in controlling symptoms in GERD patients who were unresponsive to standard-dose PPI [7]. Electroacupuncture (EA) was found to enhance the gastric peristalsis and accelerate gastric emptying and 2 Evidence-Based Complementary and Alternative Medicine improve esophageal peristalsis, as delayed gastric emptying has also been shown to contribute to failure of PPI once daily [8,9]. ...
... The median of DeMeester score is 4 (1.1-16.8), while the median of acid reflux, weak acid reflux, nonacid reflux was 11 (4)(5)(6)(7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17), 27 (7-42), and 8 (2-16), respectively. ...
... It was found to enhance gastric peristalsis and accelerate gastric emptying as delayed gastric emptying has also been shown to contribute to failure of PPI once daily [8,9]. Adding acupuncture to the standard PPT therapy was found to be more effective when compared with doubling the PPI dose in controlling symptoms in GERD patients who were unresponsive to standard-dose PPI [7]. Needleless TEA does not damage the skin and prevent the spread of infection or disease so that is more easily accepted in clinic. ...
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Objective . To investigate effects and possible mechanisms of transcutaneous electrical acustimulation (TEA) performed by a wearable watch-size stimulator for refractory gastroesophageal reflux disease (RGERD). Methods . Twenty patients diagnosed as RGERD were enrolled in the study and randomly divided into four groups: esomeprazole group (Group A), esomeprazole combined with TEA group (Group B), esomeprazole combined with sham-TEA group (Group C), and esomeprazole combined with domperidone group (Group D). HRM and 24 h pH-impedance monitoring and GerdQ score were used to measure related indexes before and after treatment. Results . (1) TEA significantly increased LESP, compared with PPI treatment only or PPI plus sham-TEA. After pairwise comparison, LESP of Group B was increased more than Group A ( P = 0.008 ) or Group C ( P = 0.021 ). (2) PPI plus TEA decreased not only the number of acid reflux episodes but also the number of weak acid reflux episodes ( P = 0.005 ). (3) Heartburn and reflux symptoms were improved more with PPI + TEA than with PPI treatment only or PPI plus sham-TEA (GerdQ scores, P = 0.001 ). Conclusion . TEA can improve symptoms in RGERD patients by increasing LESP and decreasing events of weak acid reflux and acid reflux; addition of TEA to esomeprazole significantly enhances the effect of TEA.
... Most patients with GERD require long-term therapy, as it is a chronic condition [4]. The standard treatment for GERD is known as a proton pump inhibitor (PPI), which heals the esophageal mucosa and eases the symptoms of GERD; the PPI has become a mainstay of GERD treatment [5]. However, approximately 20 % to 30 % of GERD patients continue to experience symptoms despite PPI treatment [6]. ...
... For this reason, interest is growing in complementary and alternative medicine-including acupuncture [5]. ...
... Participants will be excluded if they (1) have any current symptoms related to a structural disease that has been confirmed by endoscopy (e.g., gastrointestinal cancer, eosinophilic esophagitis, candida esophagitis, etc.); (2) have severe dysphagia, hematemesis, weight loss, or hematochezia; (3) have suffered from gastrointestinal cancer during the 5 years before the study begins; (4) have received chemotherapy for cancer during the month before the study begins; (5) have been diagnosed with ischemic heart disease (e.g., angina pectoris or myocardial infarction); (6) have an artificial cardiac pacemaker in the chest; (7) have experienced a hypersensitivity reaction after an acupuncture treatment, or show any other contraindications; (8) are taking part in any other clinical trial that could affect the results of this trial, or are being treated for GERD using any other Korean medical method (a minimum wash-out period of 2 weeks will be required for participation in this trial); (9) have difficulties attending the trial (e.g., serious mental illness, dementia, drug addiction, severe disorders in vision or hearing, illiteracy, time constraints, etc.), and (10) are pregnant or breastfeeding. ...
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Background: Gastroesophageal reflux disease lowers the quality of life and increases medical costs. Electroacupuncture has been used to ease symptoms and improve gastrointestinal motility in patients with gastroesophageal reflux disease. The main purposes of this study are to evaluate the efficacy and safety of this procedure. Methods/design: This is a protocol for a randomized, patient-blinded, assessor-blinded, sham-controlled trial. Sixty participants with symptoms of gastroesophageal reflux disease, who have previously undergone standard treatment, will be recruited from August 2015 at Kyung Hee University Korean Medicine Hospital. The participants will be allocated to either the electroacupuncture (n = 30) or the sham electroacupuncture group (n = 30); the allocation will be concealed from both the participants and the assessors. The EA group will undergo penetrating acupuncture at 18 fixed points and two optional points chosen using the pattern identification for gastroesophageal reflux disease. Electrical stimulation will be applied at some of the acupoints. The sham electroacupuncture group will undergo nonpenetrating acupuncture without electrical stimulation at 18 nonspecific points, each of which will be only 2 cm away from the true acupoints used in the electroacupuncture group. In both groups, the procedure will be performed using the Park device. The treatment will last for 6 weeks (with two sessions each week), and the outcome will be evaluated at baseline, 3 weeks, and 6 weeks. The primary outcome will be the proportion of responders with adequate symptom relief, whereas the secondary outcomes will comprise the results of the Nepean dyspepsia index; the Korean gastrointestinal symptom rating scale; the EQ-5D™; levels of gastrin, motilin, and inflammatory cytokines; the perceived stress scale; the qi-stagnation questionnaire; the patient global impression of change; and the spleen qi deficiency questionnaire. Discussion: The results of this trial will provide information about the efficacy and safety of electroacupuncture in the treatment of gastroesophageal reflux disease symptoms, as well as evidence regarding the use of electroacupuncture to treat gastroesophageal reflux disease in real clinical practice. Trial registration: Clinical Research Information Service Identifier, KCT0001653 . Registered on 12 October 2015.
... In one study, EA at ST36, PC6, and some other points in combination with a conventional proton pump inhibitor (PPI) was found to be more effective than doubling PPT dose in reducing symptoms of heartburn and acid regurgitation in patients with GERD. 26 In a more recent study, TEA at ST36 plus PPI was found more effective than PPI plus sham-TEA in treating reflux symptoms and elevating lower esophageal sphincter pressure in patients with refractory GERD. 12 Apparently more controlled studies are needed to establish the role of EA for treating GERD. ...
... Although the exact mechanisms involved in the ameliorating effects of EA on GI motility diseases are not completely known, basic and clinical research findings seem to support following mechanisms: EA activates somatic and peripheral nerves, sending an afferent signal to the nucleus tractus solitarii, resulting in an enhanced vagal efferent flow to the GI tract, 32 leading to improved GI motility. As discussed in a previous review, 7 EA has been shown to increase lower esophageal sphincter pressure in patients with GERD but reduce lower esophageal sphincter pressure in an animal model of esophagitis, 24,26 enhance antral contractions, 33 improve gastric dysrhythmias, 10 accelerate gastric emptying, 14 and improve colonic motility. 34 Enhancement of vagal activity has been consistently reported with EA and TEA assessed by the spectral analysis of heart rate variability or pancreatic polypeptide. ...
Article
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Functional gastrointestinal (GI) diseases are common and there are patients who are refractory to medical therapies as not all treatments work in all patients. Consequently, a large number of patients with functional GI diseases use complementary and alternative medicine, such as acupuncture or electroacupuncture (EA). In this issue, Zheng et al. reported interesting results of a multi‐center placebo‐controlled clinical study on the use of EA for treating refractory functional dyspepsia; another study reported a multi‐center clinical trial on EA for chronic functional constipation; Liang et al. studied mechanisms of EA involving enteric nervous system and neurotransmitters in treating constipation in rats. While controversial reports are available in the literature, EA with appropriate methodologies as shown in these recent studies is believed to be effective in treating certain functional GI diseases. In this mini‐review, a number of clinical studies, including those included in this issue on the use of EA for treating gastro‐esophageal reflux, functional dyspepsia, irritable bowel syndrome, and constipation are reviewed. Some critically important issues, such as the choice of stimulation parameters for EA, the administration frequency of the therapy, and the appropriate choice of placebo for clinical research are also discussed. Mechanisms of action involved in the therapeutic effects of EA for gut dysmotility and future research directions are also presented.
... Our research shows that TEAS combined with PPI can significantly improve all symptoms and signs of LPRD and improve their quality of life, except intralaryngeal granulomas. A randomized controlled clinical study [33] pointed out that adding acupuncture at PC6 and other acupoints to conventional PPI therapy was more efficient than doubling the PPI dose toreduce heartburn and acid reflux symptoms. In our study, heartburn symptoms improved significantly in both groups after treatment, but the differences between the two groups were not statistically different. ...
Article
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Purpose To determine the efficacy of transcutaneous electrical acupoint stimulation (TEAS) combined with proton pump inhibitor (PPI) therapy on symptoms and signs of patients with suspected laryngopharyngeal reflux disease (LPRD). Methods This was a prospective randomized controlled study. Seventy patients with reflux symptom index (RSI) > 13 and reflux finding score (RFS) > 7 were recruited and received PPI alone (control group) or TEAS combined with PPI (experimental group) for 12 weeks. Patients in the experimental group received TEAS at Tiantu (RN22), Renying (ST9), and Neiguan (PC6) once a day, five times a week. RSI, RFS, throat pain visual analog score (VAS), and LPR–health-related quality-of-life (LPR–HRQL) scores were evaluated at baseline and after 4 and 12 weeks. Results The decreases in total RSI and RFS, along with several subscores, were significantly higher in the experimental group than in the control group after 12 weeks (P < 0.05). The throat pain VAS and LPR–HRQL scores decreased significantly at 4 and 12 weeks after treatment in both groups, with significant differences between the groups (P < 0.001). No severe adverse events occurred, and the rates of adverse events were similar between the two groups. Conclusion Compared with PPI alone, TEAS combined with PPI showed a significantly greater improvement in symptoms, signs, and quality of life in the treatment of LPRD without increasing the occurrence of adverse effects. Therefore, TEAS could serve as a useful and safe treatment method for LPRD. Trial registration Chinese Clinical Trial Registry, ChiCTR2100046755.
... La primera evidenció, en un estudio de 30 pacientes con pirosis refractaria a IBP, ser más efectiva en la mejoría de los síntomas que duplicar la dosis de IBP. 65 La hipnoterapia, en cambio, fue evaluada en la PF, demostrándose, en un pequeño estudio de 9 pacientes, una disminución significativa de los síntomas y de la hipervigilancia esofágica (ansiedad visceral) así como una mejoría de la calidad de vida. 66 Manejo del paciente con ERGE extraesofágico Múltiples síntomas y entidades han sido atribuidos a la ERGE, siendo denominados síntomas extraesofágicos o ERGE atípico. ...
Article
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La enfermedad por reflujo gastroesofágico constituye uno de los motivos de consulta más frecuentes en la práctica gastroenterológica. Su diagnóstico es un desafío ya que los síntomas típicos suelen tener una baja sensibilidad y especificidad. No menos desafiante es su abordaje terapéutico, ya que requiere de un enfoque integral que debe tener en cuenta la presentación sintomática (síntomas típicos esofágicos o síntomas extraesofágicos), los hallazgos estructurales endoscópicos y las características motoras y funcionales. La correcta identificación de los fenotipos de la enfermedad por reflujo gastroesofágico es crucial para direccionar en cada caso el mejor tratamiento. En esta revisión, se propone otorgar al lector las mejores opciones terapéuticas según cada fenotipo y de acuerdo con las mejores evidencias disponibles en la actualidad.
... В одной из групп пациенты вместе со стандартной дозой ИПП проходили лечение акупунктурой, а в другой -получали двой ную дозу ИПП. Было продемонстрировано, что в группе лиц, получивших 10 сеансов акупунктуры в течение 4 недель, было достигнуто более существенное снижение частоты и выраженности изжоги в дневное и ночное время, а также повышение параметров КЖ, по сравнению с лицами, получавшими двойную дозу ИПП [73]. К сожалению в этом исследовании не было указано, имели ли обследованные пациенты ФИ и перекрест ГЭРБ и ФИ. ...
... Analysis of results obtained allows to assume that acupuncture course normalized motor skills of esophagus and stomach [25], which also had been approved bu results of other studies [26,27]. Studies named show efficiency of acupuncture in treatment of GERD patients, however, pathogenetic mechanisms of treatment mechanism in this group of patients are not disclosed. ...
... 49 El papel de la medicina alternativa y complementaria en la pirosis funcional ha sido apenas estudiado; se ha demostrado que la acupuntura mejora la pirosis diurna y nocturna como un agregado a la terapia en pacientes con pirosis que han fallado al tratamiento con dosis estándar de IBP versus duplicar la dosis de IBP. 50 Sin embargo, el grupo de pacientes estudiado no fue bien caracterizado, pero es probable que la pirosis funcional sola o en superposición con ERGE representara la mayoría de estos pacientes. ...
Article
Rome IV incorporated a new diagnostic category into the functional esophageal disorders group called reflux hypersensitivity. This new name replaced the term hypersensitive esophagus and included patients with normal acid reflux parameters but with symptomatic correlation with reflux events. Functional heartburn, which denoted lack of correlation between symptoms and reflux events in the background of normal pH test, and reflux hypersensitivity, should be excluded in heartburn patients who failed proton pump inhibitor treatment. Reflux hypersensitivity patients demonstrates esophageal hypersensitivity to reflux (any type), and both, reflux hypersensitivity and functional heartburn’s symptoms are driven by central and peripheral sensitization. The correct differentiation between these two esophageal disorders allows a therapeutic approach with greater chance of success. Neuromodulators are considered the mainstay of treatment for these patients even though patients with reflux hypersensitivity demonstrate response to anti-reflux treatment as well.
... e z-score analyses in the present Evidence-Based Complementary and Alternative Medicine study revealed that some acupoints were statistically more frequently prescribed in certain cases. For example, CV12 had a high z-score in Case 2, which can be explained by reference to previous studies showing that CV12 is commonly prescribed to treat heartburn [23] and gastroesophageal reflux disease [24]. On the other hand, BL23, GB30, and GV3, which are all located around the back and hips, had high z-scores in Case 8, which was characterised by primary symptoms of low back pain. ...
Article
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Objective: Because individual acupoints have a wide variety of indications, it is difficult to accurately identify the associations between acupoints and specific diseases. Thus, the present study aimed at revealing the commonality and specificity of acupoint selections using virtual medical diagnoses based on several cases. Methods: Eighty currently practicing Korean Medicine doctors were asked to prescribe acupoints for virtual acupuncture treatment after being presented with medical information extracted from 10 case reports. The acupoints prescribed for each case were quantified; the data were normalised and compared among the 10 cases using z-scores. A hierarchical cluster analysis was conducted to categorise diseases treated based on the acupoint prescription patterns. Additionally, network analyses were performed on the acupoint prescriptions, at the individual case and cluster level. Results: Acupoints ST36, LI4, and LR3 were most commonly prescribed across all diseases. Regarding the specific acupoints prescribed in each cluster, acupoints around the disease site (knee and lower back) were frequently used in cluster A (musculoskeletal symptoms), acupoints LI4, LR3, PC6, and KI3 were frequently used in cluster B (psychiatric symptoms), and acupoints ST36, LI4, LR3, PC6, CV12, and SP6 were frequently used in cluster C (several symptoms of diseases of internal medicine). Conclusions: The present study identified the commonality and specificity of acupoint selections based on virtual acupuncture treatments prescribed by practicing clinicians. Acupoint selection patterns, which were defined using a top-down approach in previous studies and classical medical texts, may be further elucidated using a bottom-up approach based on patient medical records.
... Hypnotherapy may be worth considering for functional heartburn but adequate randomized controlled evidence is lacking [36]. A randomized trial of acupuncture (and PPI) versus doubling the PPI dose in refractory heartburn showed daytime and night-time heartburn, and regurgitation improved to a greater extent in the acupuncture arm [104]. Replication of these data is needed. ...
Article
Gastroesophageal reflux disease (GERD) is a common disorder, and empirical proton pump inhibitor (PPI) treatment is often the first step of management; however, up to 40% of patients remain symptomatic despite PPI treatment. Refractory reflux refers to continued symptoms despite an adequate trial of PPI, and management remains challenging. The differential diagnosis is important; other oesophageal (e.g. eosinophilic oesophagitis) and gastroduodenal disorders (e.g. functional dyspepsia) should be ruled out, as this changes management. A combination of clinical assessment, endoscopic evaluation and in selected cases oesophageal function testing can help characterize patients with refractory reflux symptoms into oesophageal phenotypes so appropriate therapy can be more optimally targeted. Medical options then may include adding a H2 receptor antagonist, alginates, baclofen or antidepressant therapy, and there is emerging evidence for bile acid sequestrants and diaphragmatic breathing. The demonstration of a temporal association of symptoms with reflux events on pH‐impedance testing (reflux hypersensitivity) serves to focus the management on modulating oesophageal perception and reducing the reflux burden, or identifies those with no obvious pathophysiologic abnormalities (functional heartburn). Anti‐reflux surgery based on randomized controlled trial evidence has a role in reflux hypersensitivity or continued pathological acid reflux despite PPI in carefully considered, fully worked up cases that have failed medical therapy; approximately two of three cases will respond but there is a small risk of complications. In patients with persistent volume reflux despite medical therapy, given the lack of alternatives, anti‐reflux surgery is a consideration. Promising newer approaches include endoscopic techniques. This review aims to summarize current diagnostic approaches and critically evaluates the evidence for the efficacy of available treatments. Abstract
... There may be overlap with non-acid reflux due to a number of potential mechanisms, including altered mucosal permeability related to reflux or stress or superficial localization of afferent nociceptive neurons [35][36][37][38]. Some treatment options include tricyclic antidepressants, gabapentin, selective serotonin and norepinephrine reuptake inhibitors, clonidine, theophylline, and non-pharmacologic neuromodulatory treatment therapy (cognitive behavioral therapy, hypnosis, group therapy, acupuncture) [39][40][41][42]. ...
Article
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Purpose of review: This narrative review focuses on the presentation, contributing factors, diagnosis, and treatment of non-acid reflux. We also propose algorithms for diagnosis and treatment. Recent findings: There is a paucity of recent data regarding non-acid reflux. The recent Porto and Lyon consensus statements do not fully address non-acid reflux or give guidance on classification. However, recent developments in the lung transplantation field, as well as older data in the general population, argue for the importance of non-acid reflux. Extrapolating from the Porto and Lyon consensus, we generally classify pathologic non-acid reflux as impedance events > 80, acid exposure time < 4%, and positive symptom correlation on a standard 24-h pH/impedance test. Other groups not meeting this criteria also deserve consideration depending on the clinical situation. Potential treatments include lifestyle modification, increased acid suppression, alginates, treatment of esophageal hypersensitivity, baclofen, buspirone, prokinetics, and anti-reflux surgery in highly selected individuals. More research is needed to clarify appropriate classification, with subsequent focus on targeted treatments.
... There are currently no studies that evaluated the primary role of various alternative and complementary medicine techniques in functional heartburn. However, in one small sample study of 30 heartburn patients who failed standard dose PPI and were randomized to add on acupuncture or double dose PPI, 10 acupuncture sessions over 4 weeks provided a significant decrease in the mean daytime heartburn, nighttime heartburn and acid regurgitation scores compared with those receiving double dose PPI 66 . Mean general health score was significantly improved only in those receiving acupuncture. ...
Article
BEST PRACTICE ADVICE 1: A diagnosis of functional heartburn should be considered when retrosternal burning pain or discomfort persists despite maximal (double-dose) proton pump inhibitor (PPI) therapy taken appropriately before meals during a 3-month period. BEST PRACTICE ADVICE 2: A diagnosis of functional heartburn requires upper endoscopy with esophageal biopsies to rule out anatomic and mucosal abnormalities, esophageal high-resolution manometry to rule out major motor disorders, and pH monitoring off PPI therapy (or pH-impedance monitoring on therapy in patients with proven gastroesophageal reflux disease [GERD]), to document physiologic levels of esophageal acid exposure in the distal esophagus with absence of reflux-symptom association (ie, negative symptom index and symptom association probability). BEST PRACTICE ADVICE 3: Overlap of functional heartburn with proven GERD is diagnosed according to Rome IV criteria when heartburn persists despite maximal PPI therapy in patients with history of proven GERD (ie, positive pH study, erosive esophagitis, Barrett's esophagus, or esophageal ulcer), and pH impedance testing on PPI therapy demonstrates physiologic acid exposure without reflux-symptom association (ie, negative symptom index and symptom association probability). BEST PRACTICE ADVICE 4: PPIs have no therapeutic value in functional heartburn, the exception being proven GERD that overlaps with functional heartburn. BEST PRACTICE ADVICE 5: Neuromodulators, including tricyclic antidepressants, selective serotonin reuptake inhibitors, tegaserod, and histamine-2 receptor antagonists have benefit as either primary therapy in functional heartburn or as add-on therapy in functional heartburn that overlaps with proven GERD. BEST PRACTICE ADVICE 6: Based on available evidence, acupuncture and hypnotherapy may have benefit as monotherapy in functional heartburn, or as adjunctive therapy combined with other therapeutic modalities. BEST PRACTICE ADVICE 7: Based on available evidence, anti-reflux surgery and endoscopic GERD treatment modalities have no therapeutic benefit in functional heartburn and should not be recommended.
... 93 In small studies in patients with functional heartburn, esophageal-directed hypnotherapy, acupuncture, and deep breathing have been shown to reduce heartburn and esophageal hypersensitivity, although biofeedback was less helpful. [94][95][96][97] There are also some data on using cognitive behavioral therapy (CBT) in the management of patients with functional esophageal disorders. Li and colleagues studied 115 patients with NERD (diagnosed only based on endoscopy) and mood disorders randomized to receive drug (omeprazole and domperidone) alone, CBT alone, or drug plus CBT. ...
Article
The focus on a symptom-based definition for gastroesophageal reflux disease (GERD) in adults and children has contributed to widespread use of acid suppression medications in patients with so-called typical reflux symptoms to treat the possibility of acid-mediated disease. Diagnostic testing with upper endoscopy, esophageal biopsies, ambulatory reflux monitoring, and/or esophageal manometry is often pursued when patients do not respond optimally to these medications. By using information from this diagnostic testing, GERD has shifted from a single diagnosis to a phenotypic spectrum, and each phenotype has unique pathophysiologic mechanisms driving symptom perception. Understanding these mechanisms is important to tailor individualized treatment plans and guide therapeutic interventions. The aim of this article is to discuss the different reflux phenotypes, the utility of esophageal reflux testing, the mechanisms underlying symptoms, and the management strategies for each phenotype.
... 17 It has been used for various gastrointestinal disorders, 14 18 and a significant effect on GORD and rGORD has also been demonstrated. [19][20][21] A meta-analysis including 12 studies has shown that acupuncture is effective in improving global symptoms and QOL, reducing recurrence rate and without adverse events. 20 The mechanisms underlying acupuncture's efficacy is still unclear, but may be related to the following aspects: persistent pathological oesophageal acid exposure, weakly acidic reflux episodes and reflux hypersensitivity have been thought to be responsible for rGORD. ...
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Introduction Refractory gastro-oesophageal reflux disease (rGORD) is a common disease, affecting patients’ quality of life. Since conventional medicines have limitations, like low effective rates and adverse events, acupuncture may be a promising therapy for rGORD. While no related systematic review has been published, the present study is designed to evaluate the efficacy and safety of acupuncture for rGORD. Methods and analysis PubMed, the Cochrane Central Register of Controlled Trials and Chinese electronic databases, including China National Knowledge Infrastructure, Wan Fang database, VIP, SinoMed and the Chinese Clinical Trial Registry, will be searched from establishment of the database to 31 August 2019. There will be no limitations on language, and all articles will be screened and collected by two reviewers independently. RevMan V.5.3.5 software will be used for meta-analysis, and the conduction of study will refer to the Cochrane Handbook for Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocol guidelines. The efficacy and safety of acupuncture for rGORD will be evaluated based on outcomes, including global symptom improvement, oesophageal sphincter function test measured by high-resolution manometry, quality of life, recurrence rate and adverse events. Ethics and dissemination There is no necessity for this study to acquire an ethical approval, and this review will be disseminated in a peer-reviewed journal or conference presentation. Trial registration number CRD42018111912.
... There have been a number of reports showing that acupuncture or electroacupuncture (EA) at PC6 and/or ST36 can effectively alleviate nausea, vomiting, and other abdominal symptoms, especially for functional dyspepsia (FD) (12). Acupuncture was reported to have a significant effect on improving rGERD patients' symptoms (13). EA was found to enhance the gastric/esophageal peristalsis and accelerate gastric emptying, as delayed gastric emptying has also been shown to contribute to failure of PPI (14,15). ...
Article
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Aims: To investigate the effects and possible mechanisms of transcutaneous electrical acustimulation (TEA) combined with deep breathing training (DBT) on refractory gastroesophageal reflux disease (rGERD). Methods: Twenty-one patients with rGERD were recruited and randomly assigned to receive either only esomeprazole (ESO, 20 mg bid) (group A, n = 7), TEA + DBT + ESO (group B, n = 7), or sham-TEA + DBT + ESO (group C, n = 7) in a four-week study. The reflux diagnostic questionnaire (RDQ) score and heart rate variability (HRV) were recorded and evaluated at baseline and at the end of each treatment. Blood samples were collected for the measurement of serum acetylcholine (Ach) and nitric oxide (NO). Esophageal manometry and 24-hour pH monitoring were performed before and after the treatment. Results: After treatment, 1) the participants in group B had significantly lower scores of RDQ and DeMeester and increased lower esophageal sphincter pressure (LESP) than those in group C (all p < 0.05), suggesting the role of TEA; 2) low frequency band (LF)/(LF + HF) ratio in groups B and C was decreased, compared with group A (p = 0.010, p = 0.042, respectively); high frequency band (HF)/(LF + HF) ratio in B and C groups was significantly increased, compared with group A (p = 0.010, p = 0.042, respectively); 3) The serum Ach in groups B and C was significantly higher than group A (p = 0.022, p = 0.046, respectively); the serum NO in groups B and C was significantly lower than group A (p = 0.010, p = 0.027, respectively). Conclusions: TEA combined with the DBT can effectively improve the reflux symptoms in rGERD patients by increasing LESP and reducing gastroesophageal reflux, which may be mediated via the autonomic and enteric mechanisms.
... Among the reasons why acupuncture might benefit patients with NCCP is a potential connection to improvements in reflux disease. For example, a 2007 study of 30 patients with classic reflux symptoms on PPI therapy found that adding acupuncture was more effective than doubling the PPI dosage in reducing heartburn symptoms over 4 weeks [63]. A recent meta-analysis of 12 randomized controlled trials reinforced these findings, demonstrating that a combination of acupuncture with conventional Western GERD management was superior to the latter alone [64]. ...
Article
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Purpose of Review Popular remedies are of ongoing interest to patients experiencing common esophageal symptoms, particularly as typical pharmacologic interventions have been subject to increased scrutiny. Herein we summarize the available data regarding potential risks and benefits of several such remedies. Recent Findings With emphasis on reflux and non-cardiac chest pain, research is ongoing into the clinical utility and diverse physiologic mechanisms underlying a variety of complementary and alternative modalities, including dietary manipulation, apple cider vinegar, melatonin, acupuncture, and various herbal products (rikkunshito, STW 5, slippery elm, licorice, and peppermint oil, among others). Summary A substantial gap persists between anecdotal and empirical understandings of the majority of non-pharmacologic remedies for esophageal symptoms. This landscape of popular treatments nevertheless raises several interesting mechanistic hypotheses and compelling opportunities for future research.
... К другим немедикаментозным альтернативным подходам лечения ГЭРБ следует отнести акупунктуру и гипнотерапию [13,14]. ...
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Aim: to describe existing approaches to the treatment of gastroesophageal reflux disease (GERD) in accordance with the requirements of evidence-based medicine, as well as to discuss controversial issues in the management of GERD patients. Key findings. Nonmedical GERD treatment should be based on the reduction of body weight by decreasing the calorie intake and its proper distribution throughout the day, as well as by increasing the level of physical activity. Proton-pump inhibitors (PPIs) are used as the main class of drugs for reflux esophagitis and non-erosive reflux disease (NERD), as well as in cases when the disease is characterized by certain specific features (e.g., the presence of night symptoms) and extraesophageal manifestations. The efficacy of PPI treatment may depend on the genetic polymorphism of the CYP2C19 cytochrome. Rabeprazole is characterized by a predominantly non-enzymatic pathway, providing a more stable pharmacokinetics profile, which is less dependent on the CYP2C19 polymorphism. The duration of the initial and maintenance PPI course is determined by the GERD form. Long-term PPI maintenance therapy is indicated for erosive esophagitis. In the presence of Barrett’s esophagus, this measure is considered from the standpoint of cancer prevention. Conclusion. The use of PPIs is considered to be the key approach in the drug treatment of GERD. The choice of a PPI is based on factors that determine the efficacy and safety of such drugs, namely the rate of the onset of acid suppressive effects, the intensity of acid suppressive effects, the time of the onset of GERD clinical remission, the dependence on the CYP2C19 genetic polymorphism, the absence of significant interaction with other drugs, as well as the presence of pleiotropic effects.
... 127 One randomized study of 30 patients with continued symptoms despite standard-dose PPI found that 10 sessions of acupuncture for 4 weeks experienced a significant improvement in day and nighttime heartburn as well as acid regurgitation. 200 Transcutaneous electrical acustimulation (TEA) TEA is the administration of pulses of electricity to acupoints on the arm or leg. One small, placebo-controlled study of 20 patients with refractory GERD found statistically significant improvements in LESP and symptom control for patients receiving twice-daily TEA for 4 weeks. ...
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Joseph Mermelstein,1 Alanna Chait Mermelstein,2 Maxwell M Chait3 1Gasteroenterology and Nutrition Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA; 2Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, NY, USA; 3Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA Abstract: A significant percentage of patients with gastroesophageal reflux disease (GERD) will not respond to proton pump inhibitor (PPI) therapy. The causes of PPI-refractory GERD are numerous and diverse, and include adherence, persistent acid, functional disorders, nonacid reflux, and PPI bioavailability. The evaluation should start with a symptom assessment and may progress to imaging, endoscopy, and monitoring of esophageal pH, impedance, and bilirubin. There are a variety of pharmacologic and procedural interventions that should be selected based on the underlying mechanism of PPI failure. Pharmacologic treatments can include antacids, prokinetics, alginates, bile acid binders, reflux inhibitors, and antidepressants. Procedural options include laparoscopic fundoplication and LINX as well as endoscopic procedures, such as transoral incisionless fundoplication and Stretta. Several alternative and complementary treatments of possible benefit also exist. Keywords: PPI failure, resistant GERD, acid-related diseases, gastroesophageal reflux disease, acid reflux, proton pump inhibitors
... Acupuncture possibly works by inhibiting intraesophageal acid and bile reflux [37] as well as increasing LES pressure and reducing TLESR [38]. One study showed that adding acupuncture is more effective than doubling the PPI dose in controlling GERD-related symptoms in patients who failed standard-dose PPI [39]. ...
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The multiethnic, multicultural spectrum of Asia makes it a suitable region for study of the role of these factors and diet on GERD prevalence, pathophysiology, and treatment. There is a paucity of studies addressing these aspects from many parts of Asia. Basic pathophysiological factors may be common with the West, but studies show differences in prevalence and intensity and recent time-trend changes. Some of these differences may be attributed to language and culture, leading to limitations in diagnosis. Although proton-pump inhibitors are the standard of care for treatment of GERD in Asia, especially in institutes, alternative treatment modalities are quite frequently in use.
... La acupuntura ha demostrado mejorar la sintomatología en pacientes resistentes al tratamiento con IBP a dosis simple cuando se utiliza en conjunto con estos; se cree que actúan aumentando la motilidad esofágica y gástrica al mismo tiempo que reducen la percepción al dolor. 54 La melatonina ha cobrado reciente importancia por su efi cacia en modelos animales; aunque los ensayos en humanos son escasos existe evidencia de su efecto benéfi co sobre los síntomas al inhibir la secreción gástrica, mejorar la actividad contráctil del EEI y reducir la infl amación. 55,56 Asimismo, diversos compuestos botánicos como el Iberogast y antioxidantes como la curcumina y la quercetina han mostrado cierta efi cacia, aunque se necesitan más estudios antes de recomendar su uso. ...
... 27 Acupuncture against doubling the proton pump inhibitor dose has exerted more effective response in reducing the symptoms in GERD patients over a period of 4 weeks. 28 The adjuvant application of melatonin with common pump inhibitors has shown successfulness in resolving the symptoms in GERD patients. 29 In an animal study, treatment of 500, 250, and 125 mg/kg of Lonicera japonica Thunb extract could dose-dependently inhibit gross esophageal and gastric mucosa lesion with the underlying mechanism, antioxidant activity. ...
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Gastroesophageal reflux disease (GERD) is a very common disease. GERD is defined as the reflux of stomach content which causes troublesome symptoms and/or complications. The management of GERD is step by step. Dietary and lifestyle modifications are the first steps. Twice-daily H2RAs at standard doses for a minimum duration of two weeks can be considered in patients with GERD who fail to respond to lifestyle and dietary modifications. If symptoms of GERD persist, once-daily Proton Pump Inhibitors (PPIs) can be recommended. Patients with an unsatisfactory response to once daily PPIs dosing can be considered to have refractory GERD. Twice-daily PPI therapy can be recommended in patients who fail to respond to once-daily PPI therapy. The add-on treatment with H2RAs, baclofen, or visceral pain modulators can be considered in selective subjects with GERD who fail to respond to twicedaily PPI. Anti-reflux surgery may be taken into account in selected patients. This review focuses on the initial and maintenance therapy of GERD and also reviews different management of recurrent and refractory GERD
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Introduction: Impaired esophageal and gastric motilities are known to contribute to symptoms of gastroesophageal reflux disease (GERD). However, there is a lack of GERD therapy, targeting both gastric and esophageal functions. This study was designed to investigate the effects of transcutaneous electrical acustimulation (TEA) on symptoms of GERD and gastroesophageal functions and possible mechanisms in patients with GERD. Methods: Thirty patients with GERD with ineffective esophageal motility were equally divided and randomized into a 4-week sham-TEA or 4-week TEA treatment. The GERD questionnaire (GerdQ), GERD health-related quality-of-life questionnaire, high-resolution esophageal manometry, a nutrient drink test, the electrogastrogram, and ECG were performed to assess the severity of reflux symptoms, low esophageal sphincter (LES) pressure, distal contractile integral (DCI), gastric accommodation, gastric slow waves (GSW), and autonomic functions, respectively. Results: Compared with sham-TEA, the 4-week TEA treatment significantly decreased the GerdQ score (P = 0.011) and GERD health-related quality of life (P = 0.028) and improved nutrient drink-induced fullness (P < 0.001) and belching (P < 0.001) in patients with GERD. Although only acute TEA significantly enhanced LES pressure (P < 0.05), both acute and chronic TEA remarkedly increased DCI (P < 0.05) and reduced the incidence of ineffective esophageal contractions during wet swallows (P = 0.02). In addition, chronic TEA significantly increased gastric accommodation and the percentage of postprandial normal GSW compared with sham-TEA and baseline. Concurrently, TEA-enhanced vagal activity (P = 0.02) and the vagal activity positively correlated with LES pressure (r = 0.528; P = 0.003) and DCI (r = 0.522; P = 0.003). Discussion: The TEA treatment performed in this study improves reflux-related symptoms, increases DCI, reduces the incidence of ineffective esophageal contractions during wet swallows, and improves gastric accommodation and slow waves. The improvement in GERD symptoms might be attributed to the integrative effects of TEA on these gastroesophageal functions mediated via the vagal mechanism.
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Gastrointestinal diseases are very common worldwide. Patients with gastroesophageal reflux disease, functional dyspepsia, irritable bowel syndrome, and inflammatory bowel diseases frequently recur to complementary medicine, including acupuncture, likely because of the recurrence of symptoms and the sometimes lack of efficacy of conventional treatments. Acupuncture is a medical practice used in Asian country with benefits for thousands years. In the last decades, growing attention has been given to acupuncture also in Western countries and many studies have investigated the role of acupuncture in gastroenterology. This review provided an overview of the effectiveness and potential mechanisms of action of acupuncture for the treatment of gastrointestinal diseases.
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Heartburn is a common symptom in clinical practice, but as many as 70% of patients have normal findings from upper endoscopy. Most of these patients have non-erosive reflux disease (NERD) or functional esophageal disorders. NERD is the most common gastroesophageal reflux disease, and functional heartburn is the most common cause for refractory heartburn. In patients with NERD, symptoms arise from gastroesophageal reflux and esophageal hypersensitivity, whereas in patients with functional heartburn, symptoms result from esophageal hypersensitivity. Diagnosis of NERD requires endoscopy and reflux testing, whereas diagnosis of functional heartburn also requires esophageal manometry. NERD is most commonly treated with medical, endoscopic and surgical anti-reflux approaches, whereas functional heartburn as well as NERD, can be treated with neuromodulators, psychological intervention and complimentary medicine options.
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In this article we present the review of the literature and our own research regarding gastroesophageal reflux disease (GERD) with cardiac manifestations. The methods of treatment of patients with GERD using mineral waters, physio- and balneotherapeutic factors, as well as acupuncture are discussed. The conclusion is drawn about the effectiveness of the use of non-pharmacological methods in mono- and complex therapy of GERD and the need for further research in this direction.
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Background/aim: Gastric dysmotility is one of pathophysiologies of gastroesophageal reflux disease (GERD). The aim of this study was to investigate the effects of transcutaneous electrical acustimulation (TEA) on gastric accommodation and gastric slow waves, and evaluate possible mechanisms in patients with GERD. Methods: Thirty patients were studied in two randomized sessions of sham-TEA and TEA with the measurements of esophageal high-resolution manometry (HRM), gastric accommodation assessed by a nutrient-drinking test, electrogastrogram (EGG), electrocardiogram (ECG), and postprandial dyspeptic symptoms. Results: Compared with sham-TEA, TEA improved nutrient drinking-induced fullness (42.0 ± 3.3 vs. 31.0 ± 3.5, P = 0.003) at 10 min after the drink, and belching right after the drink (22.0 ± 4.6 vs. 11.7 ± 3.1, P = 0.012) and at 10 min (16.0 ± 3.8 vs. 3.0 ± 1.5, P = 0.002) after the drink. TEA also improved gastric accommodation (954 ± 37 mL vs. 857 ± 47 mL, P = 0.001) and normalized maximal drink-induced impairment in gastric slow waves. Concurrently, TEA enhanced vagal activity assessed from spectral analysis of heart rate variability in the postprandial state (0.42 ± 0.03 vs. 0.49 ± 0.04, P = 0.039). The vagal activity was positively correlated with the percentage of normal slow waves (r = 0.528; P = 0.003) and negatively correlated with the regurgitation score (r = -0.408, P = 0.025). Conclusions: Acute TEA increases gastric accommodation, improves gastric slow waves, and reduces postprandial fullness and belching, possibly mediated via the vagal mechanisms.
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BACKGROUND Gastroesophageal reflux disease (GERD) is a pathological condition caused by the reflux of stomach contents into the esophagus. GERD is a multifactorial disorder with an increase in prevalence worldwide. Interleukin-6 (IL-6) is a proinflammatory cytokine that is commonly found in the esophageal mucosa of GERD patients and associated with esophageal motor disorders. Acupoint-catgut embedment has long been known as adjunctive therapy for GERD. This study was aimed to establish the effect of acupoint-catgut embedment combined with medication on the IL-6 serum levels of patients with GERD. METHODS This single-blind randomized controlled trial involved 40 GERD patients from the Gastroenterology Outpatient Clinic of Cipto Mangunkusumo Hospital that were randomly allocated to either catgut-embedding therapy plus medication or sham acupuncture with medication. Catgut-embedding therapy was given two times at CV12 (Zhongwan), ST36 (Zusanli), and BL21 (Weishu) every 15 days. Serum levels of IL-6 were measured by enzyme-linked immunosorbent assay as research output. RESULTS There were no significant differences in the baseline levels of proinflammatory (IL-6) mediators between the groups. After 1-month treatment, the median levels of IL-6 were statistically insignificant decreased in catgut-embedding therapy plus medication versus sham acupuncture with medication (0.15 versus -0.16 pg/ml, respectively; p = 0.14). CONCLUSIONS The results suggest that catgut-embedding therapy has not been proven to statistically influence the levels of IL-6 in patients with GERD.
Chapter
This chapter summarizes an integrative East-West medicine approach for the treatment of reflux disease. The conceptual framework of integrative East-West medicine, therapeutic effects of acupuncture based upon mechanistic and clinical studies, nutritional recommendations from a traditional Chinese medicine (TCM) perspective, and implications upon the brain-gut-microbiota axis are all described. The potential for a brain-naso-sinus-pharynx-larynx-microbiota axis is also discussed using TCM pattern diagnosis as a point of reference for translational investigative research.
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Background Gastroesophageal reflux disease (GERD) is a common esophageal disorder. Transcutaneous electrical acustimulation (TEA), as a needleless method of electroacupuncture (EA) has been reported to improve hypotensive lower esophageal sphincters pressure (LESP) in GERD. Synchronized TEA (STEA) with inspiration has been revealed to be more effective than TEA in enhancing vagal tone. Aim To explore the effect of STEA on LESP in GERD and possible mechanisms involving autonomic functions. Methods Sixty patients were randomly allocated into a STEA group (45 patients) and sham‐TEA group (15 patients). The ECG was recorded for the assessment of the autonomic function, followed with an esophageal high‐resolution manometry (HRM) test. When the test was completed, the STEA or sham‐TEA treatment was performed for 30 minutes. Then the HRM test was repeated. Results STEA increased LESP from 21.9 to 31.9 mmHg in GERD patients (p < 0.001). A negative correlation between the percentage of STEA‐induced increase in LESP and basal LESP was observed (R = −0.471, p = 0.001). STEA reduced the number of ineffective esophageal contractions (p < 0.05). STEA rather than sham‐TEA increased vagal activity (0.27 ± 0.14 vs. 0.36 ± 0.18, p < 0.001) and decreased sympathetic activity (0.73 ± 0.14 vs. 0.64 ± 0.18, p < 0.001). Conclusions Acute STEA augments LESP in GERD and the percentage of the increase in LESP was negatively correlated with basal LESP. The effect of STEA on LESP might be mediated via autonomic function. Conflict of Interest The authors reported no conflict of interest.
Chapter
Gastroesophageal' reflux disease (GERD) is a “condition that develops when the reflux of stomach contents causes troublesome symptoms and/or complications". Since the criteria used to define GERD in epidemiological studies differ from the Montreal definition, it is difficult to know the actual prevalence of GERD in the general population. GERD is usually a clinical diagnosis based on a symptom assessment. Testing is reserved for cases in which there are warning signs of complication, atypical symptoms such that the diagnosis is in doubt, an inadequate response to medical treatment, or as a preoperative evaluation to confirm the diagnosis prior to surgical treatment. Histologic examination of distal esophageal mucosal biopsies might increase the diagnostic yield of endoscopy for GERD. Identification of reflux episodes using pH‐metry or pH‐impedance monitoring is the accepted reference standard for GERD diagnosis.
Article
Background & aims: As many as 45% of patients with gastroesophageal reflux disease (GERD) still have symptoms after receiving once-daily proton pump inhibitor (PPI) therapy. We aimed to compare reflux characteristics and patterns between responders and non-responders to once-daily PPI therapy using combined impedance-pH monitoring. Methods: Patients who reported heartburn and/or regurgitation at least twice per week for 3 months while receiving standard-dose PPI therapy were assigned to the PPI failure group (n=16). Patients who reported a complete resolution of symptoms on once-daily PPIs for at least 4 weeks were assigned to the PPI success group (n=13). We collected demographic data and subjects completed the short-form 36 and the GERD health-related quality of life questionnaires. Patients then underwent upper endoscopy and combined esophageal impedance-pH monitoring while on PPI therapy. Results: Four patients in the PPI success group (31%) and 4 patients in the PPI failure group (25%) had abnormal results from the pH test (P=1.00). Most of the patients in the PPI failure group (75%) were found to have either functional heartburn or reflux hypersensitivity with GERD. Impedance and pH parameters did not differ significantly between the PPI failure and success group. Conclusion: We found no difference in reflux characteristics between patients with GERD who had successful vs failed once-daily PPI therapy. Most patients in the PPI failure group (75%) had functional esophageal disorders.
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Esophageal symptoms can arise from gastroesophageal reflux disease (GERD) as well as other mucosal and motor processes, structural disease, and functional esophageal syndromes. GERD is the most common esophageal disorder, but diagnosis may not be straightforward when symptoms persist despite empiric acid suppressive therapy and when mucosal erosions are not seen on endoscopy (as for nonerosive reflux disease, NERD). Esophageal physiological tests (ambulatory pH or pH‐impedance monitoring and manometry) can be of value in defining abnormal reflux burden and reflux–symptom association. NERD diagnosed on the basis of abnormal reflux burden on ambulatory reflux monitoring is associated with similar symptom response from antireflux therapy for erosive esophagitis. Acid suppression is the mainstay of therapy, and antireflux surgery has a definitive role in the management of persisting symptoms attributed to NERD, especially when the esophagogastric junction is compromised. Adjunctive approaches and complementary therapy may be of additional value in management. In this review, we describe the evaluation, diagnosis, differential diagnosis, and management of NERD.
Chapter
Gastroesophageal reflux is the retrograde movement of gastric content into the esophagus. The most typical symptoms of gastroesophageal reflux disease (GERD) are heartburn and regurgitation. Nonerosive reflux disease (NERD) patients have reflux symptoms of sufficient frequency/severity to impair their quality of life without esophagitis. Mucosal damage, identified as distal esophageal mucosal breaks on endoscopy, is encountered in 20%-40% of patients with GERD symptoms. Some degree of gastroesophageal reflux is asymptomatic and normal but GERD occurs when reflux elicits tissue injury or troublesome symptoms. Different tests are available to either identify esophageal complications as surrogate markers of GERD or to quantify esophageal acid exposure and determine whether symptoms correlate with reflux events. The principles of GERD management are to minimize reflux and/or the impact of reflux by modifications in lifestyle, pharmaceuticals, or surgery. Hypnotherapy has been proposed as such an alternative therapy, especially for patients with atypical GERD symptoms.
Chapter
Nonerosive reflux disease (NERD) is defined by typical gastroesophageal reflux-related symptoms, lack of endoscopic evidence of esophageal inflammation, and increased esophageal acid exposure. NERD is the most common phenotypic presentation of gastroesophageal reflux disease (GERD), accounting for up to 70% of all patients with heartburn symptoms. NERD also accounts for the majority of the GERD patients who failed proton pump inhibitor (PPI) treatment. There is a very low, if any, rate of progression from NERD to erosive esophagitis and Barrett’s esophagus. After initial normal endoscopic evaluation, pH testing is pivotal to the diagnosis of NERD and to distinguish the disorder from functional heartburn and reflux hypersensitivity. While not yet in clinical practice, mucosal impedance is a diagnostic tool that has been shown to be useful in diagnosing NERD patients including those who are refractory to PPI therapy already during endoscopy. Treatment focuses on acid suppression, but the proportion of NERD patients responding to a standard dose of PPI is significantly lower than what has been documented in patients with erosive esophagitis. Endoscopic therapy and antireflux surgery have been demonstrated to be efficacious in carefully selected NERD patients. Alternative therapeutic strategies consist of transient lower esophageal sphincter relaxation reducers, pain modulators, psychological intervention, acupuncture, and other alternative and complementary medicine approaches.
Chapter
Complementary and alternative medicine includes practices that are not an integral part of the conventional healthcare system but are used by therapists and patients to supplement their patient’s care. The use of complementary and alternative medicine is increasing worldwide for treatment of different acute and chronic diseases including gastroesophageal reflux disease. Even 40% of parents of pediatric gastroenterology patients are using some form of complementary and alternative therapy for their child. Complementary and alternative medicine is especially used in children in whom conventional treatment has failed. In addition, school absenteeism and the occurrence of adverse effects of medication are also important predictors of using these therapies. In this chapter, we will discuss traditional Chinese medicine (acupuncture), herbals and botanicals, and mind-body therapy including breathing exercises and massage therapy. Although interest in using complementary and alternative medicine use is increasing, there is a lack of randomized controlled trials investigating its efficacy and safety in children with gastroesophageal reflux disease. Therefore, well-designed studies in this vulnerable group of children are necessary in order to determine efficacy and safety of these different treatment modalities.
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Background: Chinese medicine is widely used in the East with good results for the treatment of many diseases. Acupuncture has been increasingly used and recognized as a complementary medical treatment. Some studies on gastrointestinal motility are available; however, acupuncture effect on esophageal motility is still elusive due to the lack of studies with adequate methodology. This study aims to evaluate acupuncture effect on esophageal motility. Methods: We studied 16 (50% females, mean age 26 years) volunteers. No individual underwent acupuncture sessions previously. All individuals underwent high-resolution manometry. The test was performed in three phases: basal measurements, 20 min after acupuncture stimulation of the gastrointestinal point (ST36), or 20 min after acupuncture stimulation of a sham point (5 cm medial to ST36) (crossover). ST36 or sham points were alternated in order based on randomization. Lower esophageal sphincter (LES) resting and residual pressure, distal latency (DL) ,and distal contractility integral (DCI) were recorded. All tests were reviewed by two experienced investigators blinded to the acupuncture point. Results: LES resting pressure was significantly reduced after acupuncture (p = 0.015, Wilcoxon signed-rank test). DL was significantly increased after acupuncture (either Sham or ST36) as compared to basal measurement. Conclusion: Our results showed that acupuncture on the digestive point decreases LES basal pressure. Acupuncture may be an alternative treatment to spastic disorders of the LES.
Chapter
Complementary and alternative medicine (CAM) is frequently used by pediatric gastroenterology patients with a 1-year prevalence of use of 40 %. CAM treatments are especially popular in children with a low perceived effect of conventional treatment, which is often the case in motility and sensory disorders. This chapter discusses complementary treatment options for those disorders in which they are used fairly often: infantile colic’s, gastroesophageal reflux, functional abdominal pain and irritable bowel syndrome, and constipation. Since a wide range of CAM treatments exist and there is a dearth of good quality of evidence on safety and efficacy of these treatments in children, only those treatments that have been studied best and/or are being used most, including herbs, acupuncture, homeopathy, hypnotherapy, and manual-based therapies, are being discussed.
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Abstract Objective: This case report will describe the management of a patient with gastroesophageal reflux disease (GERD) by means of Gonstead chiropractic care. Clinical Features: A 37-year-old male presented with a two-year history of GERD, mid-thoracic pain, as well as cervical and thoracic vertebral subluxations. Lateral radiographs of the thoracic spine revealed intervertebral osteochondrosis at the mid-thoracic vertebrae. Intervention and Outcome: High velocity, low amplitude (HVLA) spinal adjustments were utilized (Gonstead technique). The patient received 12 adjustments over the span of 3.5 months that consisted primarily of HVLA adjustments to specific cervical and thoracic vertebrae. The patient experienced a reduction in frequency of GERD symptoms and vertebral subluxations following the introduction of Gonstead chiropractic care. The patient was able to maintain a care-free diet and remain asymptomatic. Conclusions: A patient suffering from GERD had successful management under Gonstead chiropractic care. The patient reported both quality of mental and physical health as improved and is currently satisfied with his condition. This case study helps validate that further research for chiropractic adjustments and its benefits to those suffering from GERD is warranted. Key Words: Chiropractic, Subluxation, Gonstead, Adjustment, Spinal Manipulation, Heartburn, GERD, Dyspepsia, Acid Reflux
Chapter
Complementary and alternative medicine (CAM) is frequently used by pediatric gastroenterology patients with a 1-year prevalence of use of 40 %. CAM treatments are especially popular in children with a low perceived effect of conventional treatment, which is often the case in motility and sensory disorders. This chapter discusses complementary treatment options for those disorders in which they are used fairly often: infantile colic’s, gastro-esophageal reflux, functional abdominal pain and irritable bowel syndrome, and constipation. Since a wide range of CAM treatments exists and there is a dearth of good quality of evidence on safety and efficacy of these treatments in children, only those treatments that have been studied best and/or are being used most, including herbs, acupuncture, homeopathy, hypnotherapy, and manual-based therapies are being discussed.
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A 36-item short-form (SF-36) was constructed to survey health status in the Medical Outcomes Study. The SF-36 was designed for use in clinical practice and research, health policy evaluations, and general population surveys. The SF-36 includes one multi-item scale that assesses eight health concepts: 1) limitations in physical activities because of health problems; 2) limitations in social activities because of physical or emotional problems; 3) limitations in usual role activities because of physical health problems; 4) bodily pain; 5) general mental health (psychological distress and well-being); 6) limitations in usual role activities because of emotional problems; 7) vitality (energy and fatigue); and 8) general health perceptions. The survey was constructed for self-administration by persons 14 years of age and older, and for administration by a trained interviewer in person or by telephone. The history of the development of the SF-36, the origin of specific items, and the logic underlying their selection are summarized. The content and features of the SF-36 are compared with the 20-item Medical Outcomes Study short-form.
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A 36-item short-form (SF-36) was constructed to survey health status in the Medical Outcomes Study. The SF-36 was designed for use in clinical practice and research, health policy evaluations, and general population surveys. The SF-36 includes one multi-item scale that assesses eight health concepts: 1) limitations in physical activities because of health problems; 2) limitations in social activities because of physical or emotional problems; 3) limitations in usual role activities because of physical health problems; 4) bodily pain; 5) general mental health (psychological distress and well-being); 6) limitations in usual role activities because of emotional problems; 7) vitality (energy and fatigue); and 8) general health perceptions. The survey was constructed for self-administration by persons 14 years of age and older, and for administration by a trained interviewer in person or by telephone. The history of the development of the SF-36, the origin of specific items, and the logic underlying their selection are summarized. The content and features of the SF-36 are compared with the 20-item Medical Outcomes Study short-form.
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Acupuncture has been used for various gastrointestinal (GI) conditions. Voluminous data support the effect of acupuncture on the physiology of the GI tract, including acid secretion, motility, neurohormonal changes, and changes in sensory thresholds. Much of the neuroanatomic pathway of these effects has been identified in animal models. A large body of clinical evidence supports the effectiveness of acupuncture for suppressing nausea associated with chemotherapy, postoperative state, and pregnancy. Prospective randomized controlled trials have also shown the efficacy of acupuncture for analgesia for endoscopic procedures, including colonoscopy and upper endoscopy. Acupuncture has also been used for a variety of other conditions including postoperative ileus, achalasia, peptic ulcer disease, functional bowel diseases (including irritable bowel syndrome and nonulcer dyspepsia), diarrhea, constipation, inflammatory bowel disease, expulsion of gallstones and biliary ascariasis, and pain associated with pancreatitis. Although there are few prospective randomized clinical studies, the well-documented physiological basis of acupuncture effects on the GI tract, and the extensive history of successful clinical use of acupuncture, makes this a promising modality that warrants further investigation.
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There is dual tactile innervation of the human hairy skin: in addition to fast-conducting myelinated afferent fibers, there is a system of slow-conducting unmyelinated (C) afferents that respond to light touch. In a unique patient lacking large myelinated afferents, we found that activation of C tactile (CT) afferents produced a faint sensation of pleasant touch. Functional magnetic resonance imaging (fMRI) analysis during CT stimulation showed activation of the insular region, but not of somatosensory areas S1 and S2. These findings identify CT as a system for limbic touch that may underlie emotional, hormonal and affiliative responses to caress-like, skin-to-skin contact between individuals.
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Functional heartburn is a common disorder and appears to be composed of several distinct subgroups. Identifying the different subgroups based on clinical history only is not achievable at present. The mechanisms responsible for pain, clinical characteristics, and the optimal therapeutic approach remain poorly understood. Response to potent antireflux treatment is relatively limited. Current and future treatment strategies for functional heartburn patients who have failed standard dose proton pump inhibitors (PPIs) include increased PPI dose in some, as well as addition of pain modulators in others.
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Acupuncture is widely used to prevent migraine attacks, but the available evidence of its benefit is scarce. To investigate the effectiveness of acupuncture compared with sham acupuncture and with no acupuncture in patients with migraine. Three-group, randomized, controlled trial (April 2002-January 2003) involving 302 patients (88% women), mean (SD) age of 43 (11) years, with migraine headaches, based on International Headache Society criteria. Patients were treated at 18 outpatient centers in Germany. Acupuncture, sham acupuncture, or waiting list control. Acupuncture and sham acupuncture were administered by specialized physicians and consisted of 12 sessions per patient over 8 weeks. Patients completed headache diaries from 4 weeks before to 12 weeks after randomization and from week 21 to 24 after randomization. Difference in headache days of moderate or severe intensity between the 4 weeks before and weeks 9 to 12 after randomization. Between baseline and weeks 9 to 12, the mean (SD) number of days with headache of moderate or severe intensity decreased by 2.2 (2.7) days from a baseline of 5.2 (2.5) days in the acupuncture group compared with a decrease to 2.2 (2.7) days from a baseline of 5.0 (2.4) days in the sham acupuncture group, and by 0.8 (2.0) days from a baseline if 5.4 (3.0) days in the waiting list group. No difference was detected between the acupuncture and the sham acupuncture groups (0.0 days, 95% confidence interval, -0.7 to 0.7 days; P = .96) while there was a difference between the acupuncture group compared with the waiting list group (1.4 days; 95% confidence interval; 0.8-2.1 days; P<.001). The proportion of responders (reduction in headache days by at least 50%) was 51% in the acupuncture group, 53% in the sham acupuncture group, and 15% in the waiting list group. Acupuncture was no more effective than sham acupuncture in reducing migraine headaches although both interventions were more effective than a waiting list control.
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Most controlled trials of acupuncture have used minimal, superficial, sham, or 'placebo' acupuncture. It has recently been demonstrated that light touch of the skin stimulates mechanoreceptors coupled to slow conducting unmyelinated (C) afferents resulting in activity in the insular region, but not in the somatosensory cortex. Activity in these C tactile afferents has been suggested to induce a 'limbic touch' response resulting in emotional and hormonal reactions. It is likely that, in many acupuncture studies, control procedures that are meant to be inert are in fact activating these C tactile afferents and consequently result in the alleviation of the affective component of pain. This could explain why control interventions are equally effective as acupuncture in alleviating pain conditions that are predominantly associated with affective components such as migraine or low back pain, but not those with a more pronounced sensory component, such as osteoarthritis of the knee or lateral epicondylalgia.
Article
Nonerosive reflux disease is defined as the presence of typical symptoms of gastroesophageal reflux disease caused by intraesophageal acid in the absence of visible esophageal mucosal injury at endoscopy. Recent studies demonstrate that it is a chronic disease with a significant impact on quality of life, and it is very common in primary care settings. Treatment with acid inhibitory agents is effective, and proton pump inhibitors are the most effective form of therapy.
Article
Proton pump inhibitors (PPIs) are drugs which irreversibly inhibit proton pump (H+/K+ ATPase) function and are the most potent gastric acid-suppressing agents in clinical use. There is now a substantial body of evidence showing improved efficacy of PPIs over the histamine H2 receptor antagonists and other drugs in acid-related disorders. Omeprazole 20 mg/day, lansoprazole 30 mg/day, pantoprazole 40 mg/day or rabeprazole 20 mg/day for 2 to 4 weeks are more effective than standard doses of H2-receptor antagonists in healing duodenal and gastric ulcers. Patients with gastric ulcers should receive standard doses of PPIs as for duodenal ulcers but for a longer time period (4 to 8 weeks). There is no conclusive evidence to support the use of a particular PPI over another for either duodenal or gastric ulcer healing. For Helicobacter pylori- positive duodenal ulceration, a combination of a PPI and 2 antibacterialswill eradicate H. pylori in over 90% of cases and significantly reduce ulcer recurrence. Patients with H. pylori- positive gastric ulcers should be managed similarly. PPIs also have efficacy advantages over ranitidine and misoprostol and are better tolerated than misoprostol in patients taking nonsteroidal anti-inflammatory drugs (NSAIDs). In endoscopically proven gastro-oesophageal reflux disease, standard daily doses of the PPIs are more effective than H2-receptor antagonists for healing, and patients should receive a 4 to 8 week course of treatment. For severe reflux, with ulceration and/or stricture formation, a higher dose regimen (omeprazole 40mg, lansoprazole 60mg, pantoprazole 80mg or rabeprazole 40mg daily) appears to yield better healing rates. There is little evidence that PPIs lead to resolution of Barrett's oesophagus or a reduction of subsequent adenocarcinoma development, but PPIs are indicated in healing of any associated ulceration. In Zollinger-Ellison syndrome, PPIs have become the treatment of choice for the management of gastric acid hypersecretion.
Article
Six randomized, placebo controlled studies were performed to investigate the effect of electroacupuncture on gastric acid output in 38 healthy males. Electroacupuncture decreased basal acid output when compared to placebo acupuncture [from 3.50±0.59 mmol/hr to 2.54±0.56 mmol/hr (P<0.05)] as well as sham feeding-stimulated acid output [from 18.52±2.25 mmol/hr to 5.38±2.11 mmol/hr (P<0.005)], but had no effect on the pentagastrin stimulated acid output. The inhibitory effect of acupuncture on sham feeding-stimulated acid output was not affected by local anesthesia of the acupoint, but was prevented by a prior intravenous naloxone injection. Acupuncture did not alter plasma gastrin levels (20.7±7.6 μg/liter, vs control 21.2±7.2 μg/liter) but naloxone increased it (26.1±14.5 μg/liter) (P<0.05). We conclude that the antisecretory effects of electroacupuncture do not result from decreased gastrin release or decreased parietal cell sensitivity to gastrin, but are mediated through naloxone-sensitive opioid neural pathways and vagal efferent pathways.
Article
The effects of therapeutic acupuncture on gastric acid secretion on pain relief in chronic duodenal ulcer patients were studied. Ten adult Nigerian patients with clinical, endoscopic as well as radiological evidence of duodenal ulcer constituted the "Ulcer Group." Four other patients who gave history of dyspepsia formed the "Dyspeptic Group." Pentagastrin stimulation test was performed on all subjects pre- and post-acupuncture therapy. The classical Chinese acupuncture loci were employed. The mean Basal Acid Output (BAO) in the duodenal ulcer group was markedly reduced from 4.04 +/- 1.01 mMols/hour to 1.05 +/- 2.5 mMols/hour. The mean Maximal Acid Output (MAO) was lowered from 34.72 +/- 13.81 mMols/hour to 15.34 +/- 4.01 mMols/hour. The difference was statistically significant (P less than 0.001). It is more probable, therefore, that the relief of pain is attributable to the therapeutic inhibition of gastric hyperacidity in our patients. Thus, though pain relief has been previously demonstrated in response to acupuncture, the results of this investigation have gone further to show that acupunture achieves symptomatic relief through therapeutic gastric depression in duodenal ulcer patients.
Article
Dysphagia has been successfully treated by low-frequency transcutaneous nerve stimulation (TNS) in two patients with achalasia and in six patients with systemic sclerosis. A 30- to 45-min stimulation session was followed by augmentation of peristalsis in the lower half of the esophagus and relaxation of the gastroesophageal sphincter, with relief of dysphagia. The sclerotic patients were also relieved of invaliding Raynaud's phenomenon. One 30-min daily stimulation session, and later one session every 2nd or 3rd day, was sufficient to prevent relapse. After months or years of TNS treatment the stimulation could in three patients be withdrawn with no recurrence. A stimulation session produced about 30% increase in plasma vasoactive intestinal polypeptides. Activation of this neuromodulator is considered to be the cause of the beneficial effects on dysphagia and Raynaud's phenomenon.
Article
Effects of acupuncture and electroacupuncture (EAP) on gastric secretion were studied in the interdigestive state of five conscious dogs prepared with esophagostomy and gastric cannulas. Both EAP and acupuncture without electrical stimulation produced significant increases in gastric secretion of bicarbonate and sodium. At the same time, a marked decrease in gastric secretion of acid was noted. EAP clearly demonstrated a greater effect on gastric secretion within these three parameters than did simple acupuncture. The fact that the effects of EAP and acupuncture on gastric secretion of bicarbonate and sodium were completely blocked by either a local anesthetic agent or anticholinergic agent indicates that gastric secretion involves a somatic afferent-visceral reflex mechanism in which a cholinergic nerve plays a role.
Article
It is well known that acupuncture is effective for treatment of gastric disease in human. We have observed the effect of acupuncturing "Zhongwan" "Neiguan" "Zusanli" on fluorohistochemical changes of G cells of antral mucosa in 42 patients with gastric disease. The results show that after acupuncture treatment the amount of fluorescent G cells and the fluorescent intensity of gastrin in the G cells were obviously decreased in patients with duodenal ulcer, as compared with that before acupuncture treatment. However, the amount of G cells was increased by acupuncture treatment in patients with chronic atrophic gastritis. These data indicate the acupuncture may regulate G cell from abnormal to normal condition in gastric mucosa of gastric disease.
Article
To develop a questionnaire to measure gastroesophageal reflux disease in the community and to test its reliability and validity. The reliability of the questionnaire was measured by a test-retest procedure in 38 outpatients and 77 community residents 25 to 74 years of age, whereas concurrent validity was evaluated by comparing findings from a physician interview with self-report data from 51 patients. For statistical analysis of the reliability of each question, the kappa statistic and the 95% confidence interval were calculated. The questionnaire was easy to understand and well accepted. The reliability (median kappa for outpatients, 0.70 [interquartile range, 0.59 to 0.81]; median kappa for population sample, 0.70 [interquartile range, 0.60 to 0.81]) and validity (median kappa, 0.62 [interquartile range, 0.49 to 0.74]) were acceptable. Our initial results suggest that this questionnaire is valid and should be applicable in population-based studies to assess gastroesophageal reflux disease.
Article
Transcutaneous stimulation (TNS) at esophageal acupuncture points decreases lower esophageal sphincter (LES) pressures in patients with achalasia. We examined the effect of TNS on esophageal motility and vasoactive intestinal peptide (VIP) levels in normal subjects. TNS was applied to either hand or foot (placebo) in 10 volunteers. Esophageal and LES pressures were recorded and blood was drawn for VIP analysis. Hand TNS improved LES relaxation and percent of peristaltic contractions to swallows, and decreased the number of spontaneous contractions. Foot TNS decreased only spontaneous contractions while LES pressures and VIP levels were unchanged. We conclude that a somatovisceral pathway involving the esophagus exists.
Article
Gastroesophageal reflux is considered a common condition, but detailed population-based data on reflux in the United States are lacking. The aim of this study was to determine the prevalence and clinical spectrum of gastroesophageal reflux in Olmsted County, Minnesota. A reliable and valid self-report questionnaire was mailed to an age- and sex-stratified random sample of 2200 Olmsted County residents aged 25-74 years. The prevalence per 100 of heartburn and/or acid regurgitation experienced at least weekly was 19.8 (95% confidence interval [95% CI], 17.7-21.9). Heartburn and acid regurgitation were associated with noncardiac chest pain (odds ratio [OR], 4.2; 95% CI, 2.9-6.0), dysphagia (OR, 4.7; 95% CI, 2.9-7.4), dyspepsia (OR, 3.1; 95% CI, 1.9-5.0), and globus sensation (OR, 1.9; 95% CI, 1.0-3.6) but not with asthma, hoarseness, bronchitis, or a history of pneumonia. Among subjects with reflux symptoms, 1.0% reported an episode of hematemesis and 1.3% had a past esophageal dilatation. Symptoms of reflux are common among white men and women who are 25-74 years of age. Heartburn and acid regurgitation are significantly associated with chest pain, dysphagia, dyspepsia, and globus sensation. The percentage of patients reporting complications is low, but the absolute number is probably considerable given the high prevalence of the condition in the community.
Article
Efficiency was studied of multimodality treatment of 586 patients with ulcer disease. Of these, 110 had gastric ulcer, 460 patients had duodenal ulcer, sixteen were suffering from both gastric and duodenal ulcer. 275 patients (46.8%) had various concurrent chronic disorders involving cardiovascular system and alimentary canal. Three groups of patients were identified: those receiving magnetoresonance therapy apart from conventional antiulcer therapy (n = 89), those undergoing laser therapy (n = 170), those exposed to hyperbaric oxygenation (HBO), variable magnetic field (VMF) and acupuncture (AP) according to generally accepted techniques. In the control group, drug therapy promoted ulcer healing in 73.3% of patients, whereas multimodality treatment involving MRT induced healing in 80.6% that of incorporating computer-aided laser therapy led to healing in 85.7 to 89.4%. HBO, VMF and AP group demonstrated healing in 92.4 to 93.7%.
Article
This meta-analysis investigated factors that may affect the risk of relapse of oesophagitis, and evaluated the predictive value of symptoms for the presence of relapse during long-term treatment. Individual data from 1154 patients included in five independently conducted, randomized, long-term clinical trials of the efficacy of different dosage regimens of omeprazole, standard ranitidine treatment and placebo for the prevention of relapse of oesophagitis were pooled for this meta-analysis. The therapeutic regimens studied were omeprazole 20 mg o.m. (OME20) in 366 patients, omeprazole 10 mg o.m. (OME10) in 225 patients, omeprazole 20 mg weekends (OMEW) in 235 patients, ranitidine 150 mg b.d. (RAN) in 179 patients, or placebo (PLA) in 149 patients. OME20 maintained 82.4% (95% CI: 78.2-86.6%) of patients in endoscopic remission over the 6-month period compared to 71.9% (95% CI: 65.5-78.3%) for OME10, 52.3% (95% CI: 44.4-60.1%) for RAN, 42.7% (95% CI: 35.8-49.5%) for OMEW, and 10.6% (95% CI: 5.0-16.3%) for PLA. A Cox's regression analysis of time to recurrence of oesophagitis showed that four factors were associated with a higher relapse rate during placebo and active maintenance therapy: (a) pre-treatment severity of oesophagitis (P < 0.0001), (b) young age (P = 0.01), (c) non-smoking (P = 0.02) and (d) moderate/severe regurgitation before entry into the trials (P = 0.03). Asymptomatic relapse of oesophagitis was uncommon, being found in only 8.6% of the patients. Maintenance treatment with omeprazole 10 and 20 mg daily is superior to all other regimens tested, and is only marginally influenced by the pretreatment severity of oesophagitis. Age contributes to the factors that influence the outcome during long-term treatment with omeprazole. Symptom relief is highly predictive for the maintenance of healing.
Article
Data are limited on the value of effective antisecretory therapy in the relief of heartburn in patients without oesophagitis. Patients with heartburn, without endoscopic signs of oesophagitis, were randomized to double-blind treatment with omeprazole, 20 or 10 mg once daily, or placebo, for 4 weeks (n = 509). Pre-treatment oesophageal acid exposure was assessed using 24-h intra-oesophageal pH monitoring. Heartburn was assessed at 2 and 4 weeks. At 4 weeks the proportion of patients with complete absence of heartburn was 46% (95% confidence interval, 39-53%) with 20 mg omeprazole, 31% (25-38%) with 10 mg omeprazole, and 13% (7-20%) with placebo. Satisfaction with therapy was reported by 66%, 57%, and 31% of the patients, respectively. Omeprazole, 20 and 10 mg once daily, provides rapid relief of heartburn in patients without endoscopic oesophagitis.
Article
Evaluation of new patients with noncardiac chest pain (NCCP) may require a variety of costly tests. The aim of this study was to evaluate the efficacy of the omeprazole test (OT) in diagnosing gastroesophageal reflux (GERD) in patients with NCCP and estimate the potential cost savings of this strategy compared with conventional diagnostic evaluations. Thirty-nine patients referred by cardiologists were enrolled. Baseline symptoms were recorded, and the patients were randomized to either placebo or omeprazole (40 mg AM and 20 mg PM) groups for 7 days. Patients were crossed over to the other arm after a washout period and repeat baseline symptom assessment. All patients underwent 24-hour esophageal pH monitoring and upper endoscopy before randomization. Thirty-seven patients (94.9%) completed the study. Twenty-three (62.2%) were classified as GERD positive and 14 as GERD negative. Eighteen (78%) GERD-positive patients and 2 (14%) GERD-negative patients had a positive OT (P < 0.01), yielding a sensitivity of 78.3% (95% confidence interval, 61.4-95.1) and specificity of 85.7% (95% confidence interval, 67.4-100). Economic analysis showed that the OT saves $573 per average patient evaluated and results in a 59% reduction in the number of diagnostic procedures. The OT is sensitive and specific for diagnosing GERD in patients with NCCP. This strategy results in significant cost savings and decreased use of diagnostic tests.
Article
Increased esophageal visceral sensitivity has been suggested to be an important factor in the development of esophageal chest pain. Transcutaneous electrical nerve stimulation (TENS) has been found effective in the treatment of visceral heart pain in severe angina pectoris, but its effect on esophageal pain perception is not known. In this study, we used the method of graded intraesophageal balloon distension to study the effects of TENS on esophageal motility and pain sensitivity. In addition, we explored the relationship between manometric findings and esophageal susceptibility to pain. TENS reduced symptoms during balloon distension significantly and decreased peristaltic velocity. Increased visceral perception was positively correlated to the amplitude and duration of the esophageal peristalsis. This study suggests a correlation between increased peristaltic waves and visceral perception in the esophagus. TENS appears to reduce esophageal pain sensitivity and thus may be a useful treatment for noncardiac chest pain of esophageal origin.
Article
Proton pump inhibitors (PPIs) are drugs which irreversibly inhibit proton pump (H+/K+ ATPase) function and are the most potent gastric acid-suppressing agents in clinical use. There is now a substantial body of evidence showing improved efficacy of PPIs over the histamine H2 receptor antagonists and other drugs in acid-related disorders. Omeprazole 20 mg/day, lansoprazole 30 mg/day, pantoprazole 40 mg/day or rabeprazole 20 mg/day for 2 to 4 weeks are more effective than standard doses of H2-receptor antagonists in healing duodenal and gastric ulcers. Patients with gastric ulcers should receive standard doses of PPIs as for duodenal ulcers but for a longer time period (4 to 8 weeks). There is no conclusive evidence to support the use of a particular PPI over another for either duodenal or gastric ulcer healing. For Helicobacter pylori-positive duodenal ulceration, a combination of a PPI and 2 antibacterials will eradicate H. pylori in over 90% of cases and significantly reduce ulcer recurrence. Patients with H. pylori-positive gastric ulcers should be managed similarly. PPIs also have efficacy advantages over ranitidine and misoprostol and are better tolerated than misoprostol in patients taking nonsteroidal anti-inflammatory drugs (NSAIDs). In endoscopically proven gastro-oesophageal reflux disease, standard daily doses of the PPIs are more effective than H2-receptor antagonists for healing, and patients should receive a 4 to 8 week course of treatment. For severe reflux, with ulceration and/or stricture formation, a higher dose regimen (omeprazole 40 mg, lansoprazole 60 mg, pantoprazole 80 mg or rabeprazole 40 mg daily) appears to yield better healing rates. There is little evidence that PPIs lead to resolution of Barrett's oesophagus or a reduction of subsequent adenocarcinoma development, but PPIs are indicated in healing of any associated ulceration. In Zollinger-Ellison syndrome, PPIs have become the treatment of choice for the management of gastric acid hypersecretion.
Article
Comparative studies of omeprazole and lansoprazole are scarce and even scarcer are comparisons of higher doses. Most of the comparative studies have assessed the effect of the two proton pump inhibitors (PPIs) on gastric acid secretion or gastric pH. Few studies have compared clinical end-points such as oesophageal healing and symptom control. To determine the clinical efficacy of omeprazole 40 mg daily as compared to lansoprazole 30 mg twice a day in symptom control of patients with severe symptomatic GERD. Ninety-six patients who failed a standard dose of lansoprazole (30 mg once daily), were enrolled in a prospective fashion from three VA medical centres and were randomized to receive 6 weeks of either omeprazole 40 mg daily or lansoprazole 30 mg twice daily. Patients reported daily on symptom severity and frequency, antacid consumption and side-effects. Forty-six patients received omeprazole and 44 lansoprazole. Although not statistically significant, there was a consistent trend of better symptom control in the omeprazole group for daytime and night-time heartburn and acid regurgitation. There was no statistical difference between the two groups in mean antacid consumption overall and at the end of each of the 6 weeks of the study. In addition, there was no significant difference in the overall frequency of side-effects between the two groups nor for each individual side-effect. Omeprazole 40 mg once daily is equally effective and tolerated as lansoprazole 30 mg twice daily in symptom control of patients with GERD.
Article
Nonerosive reflux disease is defined as the presence of typical symptoms of gastroesophageal reflux disease caused by intraesophageal acid in the absence of visible esophageal mucosal injury at endoscopy. Recent studies demonstrate that it is a chronic disease with a significant impact on quality of life, and it is very common in primary care settings. Treatment with acid inhibitory agents is effective, and proton pump inhibitors are the most effective form of therapy. (C) 2001 by Am. Coll. of Gastroenterology.
Article
Nonacid reflux may explain symptoms in acid-suppressed patients. Simultaneous intraesophageal impedance and pH measurement was used to evaluate the frequencies of postprandial acid and nonacid reflux before and after omeprazole administration. Twelve heartburn patients underwent two 2-hour studies of intraesophageal impedance and pH in the right lateral decubitus position after a refluxogenic meal; session 1 without medication, session 2 after 7 days of omeprazole twice daily. Acid and nonacid reflux were quantified. Two hundred seventeen reflux episodes were detected before and 261 after omeprazole treatment (P > 0.05). Percentage of acid reflux decreased (from 45% to 3%, P = 0.02) and nonacid reflux increased (from 55% to 97%, P = 0.03) after omeprazole. Heartburn and acid taste were more commonly linked to acid reflux but were also produced by nonacid reflux. Regurgitation was reported equally in acid and nonacid reflux. Delta(pH) > 1 did not help predict the presence of symptoms during nonacid reflux. During treatment with omeprazole, postprandial reflux becomes predominantly nonacid. Symptoms are more common with acid reflux but are also produced by nonacid reflux. Simultaneous intraesophageal impedance and pH may be useful in evaluating the role of nonacid reflux in symptoms that persist despite adequate acid suppression.
Article
There is an increasing trend towards alternative medicine usage by the general US population. However, the extent and type of supplemental alternative medicine used specifically by community-based patients with GERD is unknown. A previously validated questionnaire that included questions about patient demographics, 18 types of alternative medicine, and attitudes towards alternative and conventional medicine was utilized. Consecutive patients seen by community-based physicians in Arizona (Tucson, Phoenix, and Flagstaff) and Wisconsin (Milwaukee) for GERD received the questionnaire during the years 1999 and 2000. Patients completed the questionnaire and returned it to the Tucson VA Medical Center by mail. A total of 185 patients were surveyed (82 men, mean age 55.8 years). Of those, 61.6% used alternative medicine for any reason. However, only 3.8% of patients used supplemental alternative medicine for GERD. Females were twice as likely (95% CI, 1.10-3.67) to use alternative medicines for any reason (including GERD). Patients with daily acid regurgitation were 5.75 times (95% CI, 1.03-32.17) more likely than patients with less frequent acid regurgitation to use alternative medicines specifically for GERD. None of the other demographics, health characteristics, or attitudes were predictive of supplemental alternative medicine use for any reason (or specifically for GERD). In conclusion, only a small percentage of GERD patients seen by community-based practitioners use supplemental alternative medicine specifically for GERD symptoms, despite a higher usage of supplemental alternative medicine for non-GERD-related illness. Being female and having acid regurgitation daily were positively associated with alternative medicine usage for GERD.
Article
The frequency and amplitude of gastric peristaltic wave were significantly changed in 15 subjects when Sibai (ST 2) and Neiting (ST 44) acupoints of the Stomach Channel of Foot-Yangming were punctured. The results demonstrate that these acupoints are effective for treatment of stomach diseases, providing an experimental basis for the theory of channels and collaterals.
Article
Nausea, the unpleasant feeling that one is going to vomit, results from the stimulation of the Chemoreceptor Trigger Zone (CTZ) and Vomiting Center in the brain. Conventional medical therapy is not always effective, and medications often have severe adverse effects. Acupuncture is a treatment in which thin needles (diameter of 0.20-0.30 mm) are inserted into various points along the skin, according to energy channels (meridians) established thousands of years ago. The anti-emetic effects of acupuncture apparently stem from the resultant increase in hypophyseal secretion of beta-endorphins and ACTH, with subsequent inhibition of the CTZ and vomiting center. Acupuncture also affects the upper GI tract, decreasing acid secretion and repressing gastric arrhythmias. Clinical research has found this treatment modality to be effective for nausea, whether it be due to morning sickness in pregnant women, motion sickness in travellers, postoperative nausea or chemotherapy-induced nausea in cancer patients.
Article
Studies using ambulatory pH and esophageal bile reflux monitoring (Bilitec) have shown that both acid reflux and duodeno-gastro-esophageal reflux (DGER) frequently occur in patients with gastroesophageal reflux disease (GERD). A subset of patients with GERD has persistent reflux symptoms in spite of standard doses of proton pump inhibitors (PPIs). The aim of the present study was to investigate the role of acid and DGER in patients with reflux disease poorly responsive to PPIs. Sixty-five patients (32 men, 44 +/- 2 yr) without Barrett's esophagus and with persistent heartburn or regurgitation during standard PPI doses were studied. They underwent upper gastrointestinal endoscopy and simultaneous 24-h ambulatory pH and Bilitec monitoring while PPIs were continued. Thirty-three patients (51%) had persistent esophagitis. Seven patients (11%) had only pathological acid exposure, 25 (38%) had only pathological DGER exposure, and 17 (26%) had pathological exposure to both acid and DGER. Acid exposure under PPI was positive in only 37%, but adding Bilitec increased the diagnoses of persistent reflux to 75%. Patients with persistent esophagitis had similar acid exposure, but significantly higher DGER exposure than those without esophagitis. The highest prevalence of esophagitis was found in patients with pathological exposure to both acid and DGER; symptoms did not differ according to the type of reflux. Combined pH and Bilitec monitoring is superior to pH monitoring alone in demonstrating ongoing pathological reflux in patients with medically poorly responsive reflux disease.
Article
Little information is available about the efficacy of proton pump inhibitors (PPIs) in patients with nonerosive reflux disease (NERD). We aimed to synthesize available data and determine the effectiveness of PPIs on symptom resolution in patients with NERD. A systematic review of the literature identified studies reporting the effects of PPIs in patients with NERD. Heartburn resolution data were pooled across studies. The effectiveness of PPI therapy in inducing complete heartburn resolution was compared in patients with NERD vs. erosive esophagitis (EE). Seven trials evaluating heartburn resolution in NERD were identified. Higher proportions of patients reported achieving sufficient heartburn resolution compared with complete heartburn resolution. The effect of PPIs on sufficient heartburn resolution was observed sooner than was complete heartburn resolution. Therapeutic gain of PPI therapy over placebo ranged from 30% to 35% for sufficient heartburn control and from 25% to 30% for complete heartburn control. Pooled response rates at 4 weeks were significantly higher for patients with EE compared with NERD (56% vs. 37%, P < 0.0001). PPIs provide a more modest therapeutic gain in patients with NERD as compared with those with EE. A trend in increased therapeutic gain for NERD patients was shown throughout the 4 weeks, suggesting that 4 weeks of follow-up evaluation may be insufficient to show full therapeutic gain in this patient population.
Article
Acupuncture has been practiced empirically in China for several millennia, and is being increasingly accepted by practitioners and patients worldwide. Functional gastrointestinal disorders are common in clinical gastroenterology. The prevalence of one or more functional gastrointestinal disorders is estimated to be as high as 70% in general population using Rome diagnostic criteria. Since functional gastrointestinal disorders are diagnosed based on symptoms and the exact aetiologies for most of functional gastrointestinal disorders are not completely known, it is not unusual that the treatment for these disorders is unsatisfactory and alternative therapies are attractive to both patients and practitioners. During the latest decades, a considerable number of studies have been performed on acupuncture for the treatment of functional gastrointestinal disorders and underlying mechanisms. In this article, we reviewed available data in the literature on the applications and mechanisms of acupuncture for the treatment of functional gastrointestinal disorders, including functional oesophageal disorders, nausea and vomiting, functional dyspepsia, irritable bowel syndrome, constipation, etc. A summary is provided based on the quality and quantity of published studies regarding the efficacy of acupuncture in treating these various disorders. In addition, the methodology of acupuncture is also introduced.
Article
Ambulatory pH monitoring while on therapy is often recommended in gastroesophageal reflux disease (GERD) patients with continued symptoms. However, to date, little data exist to justify this indication. To assess the role of pH monitoring in symptomatic patients despite aggressive therapy with typical or extra esophageal GERD. Retrospective review of 2,291 ambulatory pH tracings (1999-2003) identified subgroup of studies performed on proton pump inhibitor (PPI) therapy. Patients with prior fundoplication or Barrett's esophagus were excluded. Patients grouped on predominant presenting GERD symptoms: typical (heartburn and regurgitation) or extra esophageal (chest pain, cough, hoarseness, sore throat, shortness of breath, asthma). The distribution of abnormal pH parameters in each group calculated and univariate analyses assessed the probability of abnormal pH in each group. Abnormal cutoff values traditionally used in clinical practice and more stringent cutoff values used to determine distribution of abnormality as a function of cutoff values. A total of 250 patients (mean age 54.3 yrs, 59% female) underwent pH monitoring on either daily (b.i.d.) or twice daily (q.d.) on PPI therapy: 115 (46%) with extra esophageal and 135 (54%) with typical GERD symptoms. Extra esophageal GERD patients were more likely to undergo pH monitoring on b.i.d. PPIs (OR = 2.7; 95% CI = 1.6-4.4; p < 0.01). 52 (93%) of typical and 74 (99%) of extra esophageal GERD patients on b.i.d. PPIs tested normal. The odds of a normal pH values were 11 times higher for patients on b.i.d. PPIs (OR = 11.4; 95% CI = 4.3-30.1, p < 0.01) than those on q.d. PPIs. 1) The likelihood of an abnormal esophageal pH for symptomatic GERD patients on b.i.d. PPI is very small. 2) In this group of patients failing b.i.d. PPIs causes other than GERD should be sought.
Article
Thirty-five RCTs covering 2861 patients were included in this systematic review. There is insufficient evidence to make any recommendations about acupuncture or dry-needling for acute low-back pain. For chronic low-back pain, results show that acupuncture is more effective for pain relief than no treatment or sham treatment, in measurements taken up to three months. The results also show that for chronic low-back pain, acupuncture is more effective for improving function than no treatment, in the short-term. Acupuncture is not more effective than other conventional and "alternative" treatments. When acupuncture is added to other conventional therapies, it relieves pain and improves function better than the conventional therapies alone. However, effects are only small. Dry-needling appears to be a useful adjunct to other therapies for chronic low-back pain.
Article
Proton-pump inhibitor failure has become a common clinical dilemma in gastrointestinal clinics and has been increasingly encountered at the primary care level as well. Underlying mechanisms are diverse and may overlap. Most patients who have proton-pump inhibitor failure are likely to originate from the non-erosive reflux disease phenotype. Currently, available diagnostic modalities provide limited clues to the exact underlying cause. Treatment relies primarily on escalating dosing of proton-pump inhibitors. However, new insights into the pathophysiology of proton-pump inhibitor failure are likely to provide alternative therapeutic options.
Article
To determine the value of pH testing in clinical practice in gastroesophageal reflux disease patients who failed anti-reflux treatment. Patients resistant to standard dose proton pump inhibitor or an H2-blocker underwent pH testing. Randomly selected patients from the proton pump inhibitor failure group underwent the modified acid perfusion test as compared to patients with non-erosive reflux disease. In the proton pump inhibitor failure group (n = 70), 63.8% had a normal pH test as compared to 29% in the H2-blocker group (n = 31) (P = 0.007). Sensory intensity rating and acid perfusion sensitivity score were significantly higher in the non-erosive reflux disease control group than the proton pump inhibitor failure group (P < 0.05). Most patients who continued to be symptomatic on proton pump inhibitor once daily demonstrated a normal pH test and overall lack of increased chemoreceptor sensitivity to acid.
Article
Studies have demonstrated that patients with Barrett's oesophagus have the highest oesophageal acid exposure profile, followed by erosive oesophagitis and non-erosive reflux disease patients, but the exact extent of overlap remains unknown. To determine the extent of overlap in oesophageal acid exposure among the different gastro-oesophageal reflux disease groups. A total of 121 patients with gastro-oesophageal reflux disease underwent an upper endoscopy and were classified as having Barrett's oesophagus, erosive oesophagitis and non-erosive reflux disease-all (non-erosive reflux disease-positive and functional heartburn). Subsequently, patients underwent pH testing and overlap in oesophageal acid exposure among the different gastro-oesophageal reflux disease groups was determined. Of those enrolled, 24 had Barrett's oesophagus, 30 erosive oesophagitis and 28 were non-erosive reflux disease-positive. Mean oesophageal acid exposure time was 224.8 +/- 35, 134.3 +/- 21.9 and 141.3 +/- 19.8 min for Barrett's oesophagus, erosive oesophagitis and non-erosive reflux disease-positive respectively. Per cent overlap for total, upright and supine time between non-erosive reflux disease-positive and erosive oesophagitis was 47.4%, 64.7% and 81.8%, between Barrett's oesophagus and erosive oesophagitis was 47.8%, 40.7% and 24%, and between Barrett's oesophagus and non-erosive reflux disease-positive was 31.6%, 37.5% and 20.8% respectively. Our study demonstrated a high oesophageal acid exposure overlap between patients with non-erosive reflux disease-positive and erosive oesophagitis, Barrett's oesophagus and erosive oesophagitis, as well as Barrett's oesophagus and non-erosive reflux disease-positive patients.
Article
Background: Irritable bowel syndrome (IBS), a disorder of altered bowel habits associated with abdominal pain or discomfort. The pain, discomfort, and impairment from IBS often lead to healthcare medical consultation (Talley 1997) and workplace absenteeism, and associated economic costs (Leong 2003). A recent randomized controlled trial shows variable results but no clear evidence in support of acupuncture as an effective treatment for IBS (Fireman 2001). Objectives: The objective of this systematic review is to determine whether acupuncture is more effective than no treatment, more effective than 'sham' (placebo) acupuncture, and as effective as other interventions used to treat irritable bowel syndrome. Adverse events associated with acupuncture were also assessed. Search strategy: The following electronic bibliographic databases were searched irrespective of language, date of publication, and publication status: MEDLINE, the Cochrane Central Register of Controlled Trials (CENTRAL) on The Cochrane Library, EMBASE, the Chinese Biomedical Database, the Cumulative Index to Nursing and Allied Health (CINAHL), and the Allied and Complementary Medicine Database (AMED). References in relevant reviews and RCTs were screened by hand. The last date for searching for studies was 7 February 2006. Selection criteria: Published reports of randomized controlled trials (RCTs) and quasi-randomised trials of acupuncture therapy for IBS. Data collection and analysis: All eligible records identified were dually evaluated for eligibility and dually abstracted. Methodological quality was assessed using the Jadad scale and the Linde Internal Validity Scale. Data from individual trials were combined for meta-analysis when the interventions were sufficiently similar. Heterogeneity was assessed using the I squared statistic. Main results: Six trials were included. The proportion of responders, as assessed by either the global symptom score or the patient-determined treatment success rate, did not show a significant difference between the acupuncture and the sham acupuncture group with a pooled relative risk of 1.28 (95% CI 0.83 to 1.98; n=109). Acupuncture treatment was also not significantly more effective than sham acupuncture for overall general well-being, individual symptoms (e.g., abdominal pain, defecation difficulties, diarrhea, and bloating), the number of improved patients assessed by blinded clinician, or the EuroQol score. For two of the studies without a sham control, acupuncture was more effective than control treatment for the improvement of symptoms: acupuncture versus herbal medication with a RR of 1.14(95% CI 1.00 to 1.31; n=132); acupuncture plus psychotherapy versus psychotherapy alone with a RR of 1.20 (95% CI 1.03 to 1.39; n=100). When the effect of ear acupuncture treatment was compared to an unclearly specified combination of one or more of the drugs diazepam, perphenazine or domperidone, the difference was not statistically significant with a RR of 1.49(95% CI 0.94 to 2.34; n=48). Authors' conclusions: Most of the trials included in this review were of poor quality and were heterogeneous in terms of interventions, controls, and outcomes measured. With the exception of one outcome in common between two trials, data were not combined. Therefore, it is still inconclusive whether acupuncture is more effective than sham acupuncture or other interventions for treating IBS.
Article
The aims of this study were to investigate the effects of electroacupuncture (EA) at ST36 and PC6 points on solid gastric emptying and dyspeptic symptoms in patients with functional dyspepsia. Nineteen patients with functional dyspepsia (FD) were involved in the study, consisting of two parts: (1) acute effects of EA on solid gastric emptying in FD patients with delayed gastric emptying and (2) short-term (2-week) effects of EA on symptoms in FD patients with normal gastric emptying. Results were as follows. (1) Ten of the19 patients showed delayed gastric emptying of solids, and acute EA significantly improved delayed gastric emptying; the halftime for gastric emptying was reduced from 150.3+/-48.4 to 118.9+/-29.6 min (P=0.007). (2) In the nine patients with normal gastric emptying, 2-week EA significantly decreased the symptom score, from 8.2+/-3.3 at baseline to 1.6+/-1.1 (P < 0.001) at the end of treatment. We conclude that EA at the ST36 and PC6 points accelerates solid gastric emptying in FD patients with delayed gastric emptying and relieves dyspeptic symptoms in FD patients with normal gastric emptying.
Gastric emptying of patients with persistent reflux symptoms and erosive esophagitis under PPI therapy (abstract)
  • Kudara
Kudara N, Chiba T, Orii S, Suzuki K. Gastric emptying of patients with persistent reflux symptoms and erosive esophagitis under PPI therapy (abstract). Neurogastroenterol Motil 2004; 16: 654.
oesophagus: acid reflux, bile reflux, or both?
  • Clinical Trial
  • Acupuncture
  • Ppi
  • He
  • Tb
CLINICAL TRIAL: ACUPUNCTURE AND PPI IN HE AR TB URN 1341 oesophagus: acid reflux, bile reflux, or both? Am J Gastroenterol 2004; 99: 981–8.
Acupuncture for treatment of irritable bowel syndrome Unmyelinated tactile afferents signal touch and project to insular cortex
  • B Lim
  • E Manheimer
  • L Lao
Lim B, Manheimer E, Lao L, et al. Acupuncture for treatment of irritable bowel syndrome. Cochrane Database Syst Rev 2006; 4: CD005111. 41 Olausson H, Lamarre Y, Backlund H, et al. Unmyelinated tactile afferents signal touch and project to insular cortex. Nat Neurosci 2002; 5: 900–4.