Search

Background: Up to three quarters of patients with gastroesophageal reflux disease (GERD) have symptoms, such as heartburn, but no macroscopic evidence of erosive esophagitis, making symptomatic GERD a common clinical problem in the primary care setting. Objective: To compare the efficacy and safety of omeprazole, 20 mg once daily; omeprazole, 10 mg once daily; and placebo in the treatment of symptomatic GERD without erosive esophagitis. Methods: Patients with a history of heartburn ([is greater than or equal to] 12 months) and episodes of moderate to severe heartburn on 4 or more of the 7 days before endoscopy were eligible to participate in this 4-week, randomized, double-blind, placebo-controlled trial. The absence of erosive esophagitis was established through endoscopy. Eligible patients were randomized to 1 of 3 treatment groups: omeprazole, 20 mg once daily; omeprazole, 10 mg once daily; or placebo. Patients were assessed at weeks 2 and 4. The efficacy of omeprazole for the treatment of heartburn was determined mainly through the following diary card data: daily resolution of heartburn and complete resolution of heartburn every day during 1 week of treatment. The efficacy of omeprazole for the treatment of acid regurgitation, dysphagia, epigastric pain, and nausea was also assessed. Results: Of 359 randomized patients, 355 were included in the statistical analysis (intention-to-treat population). Daily proportions of patients with no heartburn were consistently greater in the 20-mg omeprazole group (62%, day 7; 74%, day 27) than in the 10-mg omeprazole group (41%, day 7; 49%, day 27) or the placebo group (14%, day 7; 23%; day 27). Complete resolution of heartburn every day during the last treatment week was significantly (P [is less than or equal to] .002) higher in the 20-mg omeprazole group (48%) than in the 10-mg omeprazole (27%) or placebo (5%) group. Omeprazole was significantly (P [is less than or equal to] .003) more effective than placebo for the treatment of acid regurgitation, dysphagia, epigastric pain, and nausea. Conclusions: Patients with symptomatic GERD require profound acid suppression to achieve symptomatic relief. Omeprazole, 20 mg once daily, was superior to omeprazole, 10 mg once daily, and to placebo in providing early and sustained resolution of heartburn, as well as treatment of other troublesome GERD symptoms. Arch Intern Med. 2000;160:1810-1816

Intestinotrophic therapies, such as glucagon-like peptide-2 (GLP-2) analogs, may enhance intestinal adaptation and reduce dependence on parenteral nutrition (PN) in patients with intestinal failure associated with short bowel syndrome (SBS-IF). However, because GLP-2 enhances cellular growth, there is concern that GLP-2 analogs may also encourage growth of malignant cells.

One hundred two patients referred to our Esophageal Function Laboratory without endoscopic evidence of esophagitis were divided into two groups on the basis of the presence of a hiatal hernia on endoscopic examination. Fifty-three patients had a hiatal hernia and 49 did not. Both groups and 30 normal volunteer subjects had esophageal manometry and 24 hour esophageal pH monitoring. The incompetency of the cardia in patients with a hiatal hernia was dependent upon loss of components responsible for the antireflux mechanism, mainly a decrease in distal esophageal sphincter pressure and a decrease in the length of the sphincter exposed to the positive-pressure environment of the abdomen. These deficiencies were not related to the presence of a hiatal hernia and were similar to those of patients with an incompetent cardia without a hiatal hernia. Patients with a hiatal hernia and an incompetent cardia had significantly more esophageal exposure to refluxed acid than those without a hiatal hernia. On the basis of the number of reflux episodes that lasted 5 minutes or longer and radioisotope transit studies, this increased acid exposure was due to both a loss of competency of the cardia and poor esophageal clearance secondary to the presence of a hiatal hernia. Reduction of the hernia and anchoring the distal esophagus into the abdomen not only may improve the antireflux mechanism, but corrects the clearance abnormality as well. The presence of a hiatal hernia has a detrimental effect on the clearance function of the body of the esophagus and may aggravate the effects of gastroesophageal reflux due to an incompetent cardia.

'Gastro-esophageal reflux' is the passage of gastric content into the esophagus. Resulting typical symptoms are denoted as 'reflux like dyspepsia'. 'Reflux esophagitis' is the endoscopic or microscopic evidence of damage to the esophageal mucosa. Long-term intra-esophageal pH-monitoring will esablish 'pathologic gastroesophageal reflux' when 'acid exposure' time exceeds 5 % of the monitoring time. GERD, 'gastro-esophageal reflux disease', is present when symptoms and/ or esophagitis are caused by reflux. 'Columnar lined esophagus' is a better expression than 'Barret's esophagus'. Esophageal acid exposure increases during the day with a peak in the evening and little reflux after midnight. Treatment should probably be concentrated to evening time and not so much to night time.

Changes in pH in the distal esophagus to detect reflux is the basis for ambulatory intraesophageal 24-hour pH-monitoring. Patients with symptoms that do not respond to therapy, patients with atypical symptoms and patients planned for antireflux surgery should undergo pH-monitoring. Pathologic reflux is detected by calculating acid exposure time. Information on the temporal relationship between reflux episodes and symptoms, and of the temporal pattern will also be obtained. The monitoring should be performed ambulatory during 24 hours. The patient should be as unrestricted as possible, except for acit food and beverages. Many types of equipment are available. Solid state memories are preferred, glass or antimony electrodes may be used and the data analysis should be performed on an ordinary personal computer.

In these speculations of the future in gastroesophageal reflux a hope is expressed that gastro-esophageal reflux disease is accepted as a separate entity. Treatment and diagnosis should not be confused with those of ulcer disease. Reflux disease is not a problem of too much acid in the stomach, but too much acid in the wrong place, the esophagus. The problem is mainly a leaking valve. Furthermore, the expression reflux like dyspepsia should be used when esophagitis or gastroesophageal reflux disease is not established by endoscopy or pH-monitoring.