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Objective: Acid exposure time (AET) from ambulatory pH studies and reflux oesophagitis are independent measurements used by the Lyon classification to diagnose GORD. This study aimed to validate AET reference ranges and diagnostic thresholds by analysis of 96-hour wireless pH studies from healthy, asymptomatic controls (HCs) and patients with and without oesophagitis., Design: HC and consecutive patients referred for wireless pH studies (off acid suppressants for >7 days) underwent 96-hour pH studies at two tertiary referral centres. Erosive oesophagitis was categorised by the Los Angeles (LA) classification. Linear regression and receiver operating curve (ROC) analysis were performed to define optimal diagnostic cut-offs., Results: Prolonged, 96-hour pH studies were completed in 39 HCs (age 28 (18-53) years, 72% female) and 944 patients (age 46 (16-85) years, 65% female), of whom 136 (14.5%) had reflux oesophagitis. Median AET in HC was 1.3% (upper 95th percentile 4.6%) for any study day and 2.6% (upper 95th percentile 6.9%) for the worst day (24-hour period) during the study. ROC analysis for average AET differentiated HC from patients with moderate-to-severe oesophagitis (LA BCD; sensitivity 87%, specificity 95%, positive predictive value (PPV) 59%, negative predictive value 99% for a cut-off AET of 4.3%; area under the receiver operating curve 0.95). Specificity was higher, but PPV was substantially lower for severe oesophagitis (LA CD). 'Worst-day' analysis provided similar results; however, day-to-day variability was high., Conclusion: Diagnostic thresholds for average AET were identified that accurately discriminate between HCs and patients with erosive oesophagitis. The findings provide conditional support for diagnostic criteria for GORD proposed by the Lyon Consensus., Competing Interests: Competing interests: MRF has received research and/or educational funding from Medtronic, MMS/Laborie, Sandhill Scientific/Diversatek and Reckitt Benckiser. R-IR, ET, SZ, JMD, JJ, FW, TW: None declared., (© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Gastro esophageal reflux disease (GERD) is a chronic and recurrent disease, and it varies in regions. However, to date, there are no reports available on clinical features and the risk factors for the asymptomatic reflux esophagitis in Nepalese adults., Methods: Data were gathered from 142 erosive patients who had undergone endoscopy at Bir Hospital, Kathmandu. Los Angeles classification was used to grade the severity of the disease. Patients were interviewed to find out the presence of various reflux symptoms., Results: Based on the Los Angeles classification, the severity of the disease assessed was; grade A 31.8% (31/142), grade B 39.4% (56/142), grade C 33.8% (48/142), and grade D 4.9% (7/142). One hundred and twenty six (88.7%) subjects had reflux symptoms. Prevalence of asymptomatic esophagitis was 16(11.3%). Age was independently linked to asymptomatic esophagitis (P<0.05), and the odd of being asymptomatic appeared lower in younger adults (P<0.05; OR: 0.118; CI: 0.014-.994)., Conclusion: A low prevalence of asymptomatic reflux esophagitis (RE) was seen. Most subjects experienced mild to moderate RE. Age remained an independent factor associated with reflux esophagitis, and the odds of being asymptomatic was lower in younger age.

Introduction: The relationship between the Los Angeles (LA) grade of esophagitis and acid exposure by pH monitoring is unclear. The aim of this study was to correlate the results of pH testing in patients with esophagitis to determine at what LA grade of esophagitis a pH test is not necessary., Methods: A retrospective review was performed of the records of all patients who underwent upper endoscopy and were found to have esophagitis graded using the LA system and who had pH monitoring from 2014 to 2016. An abnormal pH test was determined based on the DeMeester score., Results: There were 56 patients with a median age of 57 years. Esophagitis was LA grade A in 19, B in 20, C in 15 and D in 2 patients. An abnormal pH score was present in 47 patients (84%). All patients with C or D esophagitis had an abnormal pH score compared to 79% and 75% of patients with A and B esophagitis, respectively., Conclusions: The presence of LA C or D esophagitis was always associated with increased esophageal acid exposure on pH testing and is proof of reflux disease. However, pH testing is recommended prior to antireflux surgery in patients with LA A or B esophagitis.

Some studies suggest that Helicobacter pylori (H. pylori) infection would be a protective factor for the gastroesophageal reflux. The aim of this study was to explore this fact. A group of 72 children, admitted in a pediatric gastroenterology regional center in Northeast Romania, diagnosed with gastroesophageal reflux by 24-hour continuous esophageal pH monitoring (results were interpreted using the Boix-Ochoa score), underwent upper endoscopy with gastric biopsy to detect the presence of H. pylori by the rapid urease testing and for bacteriological and histologic examination. 19 children (26.39%) had H. pylori infection, while 53 (73.61%) did not. The grade of esophagitis was classified according to the Los Angeles classification system. Out of 47 children with esophagitis A, 16 (34.04%) had H. pylori infection, while out of the 25 children with esophagitis B, only 3 (12%) had H. pylori infection, with statistic significance (χ 2 = 54.69, P << 0.05, 95% confidence interval [CI]). Regarding the value of the Boix-Ochoa score, it appears that the presence of the H. pylori determines lower pH-metry scores (F = 8.13, P = 0.0015, 95% CI). The presence of the H. pylori was not an important factor in the gastroesophageal reflux. On the other hand its relationship with esophagitis appears to be inverse ratio. The fact that the H. pylori presence is statistically greater in the grade A esophagitis could confirm the hypothesis that the bacteria would slow down the development of the esophagitis., (© 2015 International Society for Diseases of the Esophagus.)

It is important to accurately classify the severity of reflux esophagitis, because the clinical response to treatment is dependent on the severity of erosive lesions. In Japan we had used Savary-Miller classification for endoscopic grading. In this classification stage I to III encompass mucosal erosions of increasing extent, while stage IV includes all complications, which make it difficult to follow the evolution of the esophagitis and its response to treatment. A new endoscopic classification was proposed at the World Congress of Gastroenterology in Los Angeles in 1994. A mucosal break was emphasized which was defined as an area of slough or erythema with a sharp demarcation between it and the adjacent mucosa. Mucosal breaks are classified into 4 grades from A to D according to their extension. The complica- tions are not included in this grading system. Japanese study revealed that only 20 % of patients with heartburn had grade Aio D. This means that LA classification is insufficient at least in Japan. We have proposed,the modified LA classification including grade M and N, adding the original classification. Grade M pre- sents minimal change esophagitis and an undemarcated erythema after treatment of the muco- sal break using H2 blocker or PPI, whilst grade N represents no findings of esophagitis. Now this modified LA classification is widely used in Japan.

Objective: To identify criteria of pH-grams to diagnose the severity of esophagitis and preneoplastic complications of GERD., Materials and Methods: 63 patients aged from 18 to 70 with A, B, C degree of GERD, according to the Los Angeles classification and 15 patients with intestinal metaplasia of columnar epithelium and leukoplakia of the stratified squamous epithelium of the esophagogastric transition were examined. For daily intraesophageal pH-monitoring "Gastroscan-24", pH probes manufactured by ZAO NPP "Istok- system", Fryazino (Russia) were used. pH-grams were estimated according for indicators DeMeester. Endoscopy was performed by videoesofagogastroscopes of Evis Exera- system--160 and by the tools company "Olympus" (Japan)., Results: 5 options of pH-grams were selected, each of them may correspond to some degree of esophagitis, preneoplastic changes of the esophageal mucosa, esophageal and extraesophageal manifestations of GERD., Conclusion: Daily pH-monitoring of the esophagus can serve as a screening for the severity of esophagitis, preneoplastic changes of esophagogastric transition, for addressing the need of morphological studies and differential diagnosis of extraesophageal manifestations of GERD.

Aim: To investigate the relationships among subtypes of gastroesophageal reflux disease (GERD) using narrow band imaging (NBI) magnifying endoscopy., Methods: A reflux disease questionnaire was used to screen 120 patients representing the three subtypes of GERD (n = 40 for each subtypes): nonerosive reflux disease (NERD), reflux esophagitis (RE) and Barrett's esophagus (BE). NBI magnifying endoscopic procedure was performed on the patients as well as on 40 healthy controls. The demographic and clinical characteristics, and NBI magnifying endoscopic features, were recorded and compared among the groups. Targeted biopsy and histopathological examination were conducted if there were any abnormalities. SPSS 18.0 software was used for all statistical analysis., Results: Compared with healthy controls, a significantly higher proportion of GERD patients had increased number of intrapapillary capillary loops (IPCLs) (78.3% vs 20%, P < 0.05), presence of microerosions (41.7% vs 0%, P < 0.05), and a non-round pit pattern below the squamocolumnar junction (88.3% vs 30%, P < 0.05). The maximum (228 ± 4.8 vs 144 ± 4.7, P < 0.05), minimum (171 ± 3.8 vs 103 ± 4.4, P < 0.05), and average (199 ± 3.9 vs 119 ± 3.9, P < 0.05) numbers of IPCLs/field were also significantly greater in GERD patients. However, comparison among groups of the three subtypes showed no significant differences or any linear trend, except that microerosions were present in 60% of the RE patients, but in only 35% and 30% of the NERD and BE patients, respectively (P < 0.05)., Conclusion: Patients with GERD, irrespective of subtype, have similar micro changes in the distal esophagus. The three forms of the disease are probably independent of each other., (© 2013 Baishideng Publishing Group Co., Limited. All rights reserved.)

Objective: The aim of this study was to investigate whether patients with diagnosed erosive gastroesophageal reflux disease (ERD) have an increased probability of halitosis and tongue coating compared to patients with nonerosive gastroesophageal reflux disease (NERD)., Materials and Methods: Sixty-six patients (33 males and 33 females) were recruited for the study and received an upper gastrointestinal endoscopy. The presence of ERD (n = 31) and NERD (n = 35) was classified based on the Los Angeles classification for erosive changes in the esophagus. Additionally, the patients filled in a questionnaire regarding their subjective assessment of halitosis, and an organoleptic assessment of halitosis, a measurement of oral volatile sulfur compounds (VSC) with the Halimeter, and a tongue coating index were performed. ERD and NERD subjects were compared with regard to Halitosis-related clinical and anamnestic findings., Results: No statistically significant difference could be found between ERD and NERD patients regarding tongue coating index, organoleptic scores, and VSC values as well as self-perceived bad taste, tongue coating, and bad breath., Conclusions: These data suggest that halitosis is not typically associated with erosive gastroesophageal reflux disease and the presence of esophageal mucosal damage (ERD patients)., Clinical Relevance: The data of this investigation support the findings of interdisciplinary bad breath clinics that gastroesophageal reflux disease is not a leading cause for halitosis.

Background: We assessed whether the esophageal mucosa index of hemoglobin (IHb) could assist the Los Angeles (LA) classification in defining the severity of erosive reflux esophagitis (RE) and predicting the treatment response by esomeprazole., Methods: Five hundred twenty-four subjects (424 RE and 100 controls) with normal body mass index and hemoglobin had undergone endoscopy to confirm the RE grade by LA classification and to check the series of IHb values at every centimeter of the esophageal mucosa while withdrawing the endoscope to above the esophageal-gastric junction (EGJ). The RE cases had received esomeprazole for 8 weeks (40 mg/day) to assess the cumulative proportions of sustained symptomatic response (SSR)., Results: The IHb value at the EGJ was higher in RE patients than in controls (P < 0.001). Selecting 70 as the cutoff IHb value at the EGJ, the efficacy to define RE achieved 95.8% (406/424) sensitivity and 94% (94/100) specificity. For the patients with same the LA grade, the length of IHb value >70 above the EGJ (L-IHb70) that is greater than 4 cm correlated with a poor cumulative rate of SSR (P < 0.01)., Conclusion: The IHb value >70 at the EGJ is a reliable indicator of RE. The L-IHb70 can serve as a supplementary indicator to predict the response to esomeprazole index within the same LA grade.

Reflux esophagitis (RE) and columnar-lined esophagus (CLE) are frequently observed after esophagectomy. The incidence of these conditions according to time and to the route of esophageal reconstruction after esophagectomy remains unknown. The aim of this study was to clarify any changes and differences of the incidence of RE and CLE in patients who underwent gastric tube reconstruction after esophagectomy. A hundred patients who underwent cervical esophagogastrostomy after resection of the thoracic esophagus were included in this study. We reviewed their endoscopic findings at 1 month, at 1 year and at 2 years after surgery, and compared the incidence rates of RE and CLE with the passage of time and among the three reconstruction routes; a subcutaneous route, a retrosternal route, and a posterior mediastinal route. The incidence rate of RE was 42%, 37% and 38%, at 1 month, 1 year and at 2 years after surgery, respectively. There was no significant difference in the incidence of RE according to the time after surgery. The incidence rate of severe RE (Grade C and D in the Los Angeles Classification) was 9% percent at 1 month after surgery, 18% at 1 year after surgery and 22% at 2 years after surgery, significantly increasing with passage of time. The incidence rate of CLE was 0% at 1 month after surgery, 14% at 1 year after surgery and 40% at 2 years after surgery, significantly increasing with passage of time. No difference was observed in the incidence of RE and that of CLE among the three routes of esophageal reconstruction. Severe RE and CLE increase with passage of time after cervical esophagogastrostomy. Therefore, careful endoscopic follow-up is necessary for such patients irrespective of the route of esophageal reconstruction.

Objective: To establish animal models of reflux esophagitis in rats., Methods: Seventy male Sprague Dawley rats aged 8 weeks were randomly divided into 4 groups: in Group A (n=20) esophagojejunostomy was performed to induce a gastro-jejuno-esophageal reflux; in Group B (n=20) esophagoduodenostomy was performed to induce a gastro-duodeno-esophageal reflux; in Group C (n=20) total gastrectomy plus esophagojejunostomy was performed to induce a jejuno-esophageal reflux; in Group D (n=10) only was performed sham operation (control)., Result: Among 70 rats, 6 died in Group A, 7 died in Group B, 6 died in Group C, and 72.9 %(51/70) animals were completed in the study. After 12 weeks the incidence of esophageal inflammation was 100.0%; in Groups A, B and C erosion occurred in 11/14 (78.6%), 10/13 (76.9%), 3/14 (21.4%) of animals, respectively; squamous dysplasia was in 10/14 (71.4%), 10/13 (76.9%), 5/14 (35.7%) of rats, respectively; Barrett's esophagus was in 6/14 (42.9%), 5/13 (38.5%), 1/14 (7.1%), respectively. One esophageal adenocarcinoma was found in Group A; no histological changes were observed in Group D., Conclusion: The animal models of reflux esophagitis can be induced by esophagojejunostomy, esophagoduodenostomy or total gastrectomy plus esophago-jejunostomy in rats; and the former two surgical modalities are better than the later.

Background: The frequency of histological changes mimicking those described for reflux esophagitis in humans was assessed in a cohort of non-human primates (NHP)., Materials and Methods: A total of 121 consecutive esophagi (from 103 baboons and 18 macaques) were classified according to Ismail-Beiji for reflux esophagitis in humans into grade 1, grade 2 and grade 3 esophagitis., Results: Histological features compatible with reflux esophagitis were found in 28.2% of the baboons and in 22.2% of the macaques. Esophagitis grade 1 was more common in baboons (24%) than in macaques (6%), while esophagitis grade 2 was more common in macaques (17%) than in baboons (2%)., Conclusion: Although the prevalence of reflux esophagitis in man is at least 2%, only a fraction of patients demonstrate histological features consistent with grades 1, 2 or 3 esophagitis. Hence, the finding that 27% of a cohort of consecutive, unselected NHP had grades 1, 2 or 3 esophagitis at histology is remarkable. The possible causes for the difference between species, such as the oblique position often adopted by NHP during the gastric phase of digestion, the diet, regurgitation and subsequent re-ingestion, as well as the stress of NHP when kept in captivity, are reviewed.

The Los Angeles classification system is the most widely employed criteria associated with the greatest interobserver agreement among endoscopists. In Japan, the Los Angeles classification system has been modified (modified LA system) to include minimal changes as a distinct grade of reflux esophagitis, rather than as auxiliary findings. This adds a further grading M defined as minimal changes to the mucosa, such as erythema and/or whitish turbidity. The modified LA system has come to be used widely in Japan. However, there have been few reports to date that have evaluated the interobserver agreement in diagnosis when using the modified LA classification system incorporating these minimal changes as an additional grade. A total of 100 endoscopists from university hospitals and community hospitals, as well as private practices in the Osaka-Kobe area participated in the study. A total of 30 video clips of 30-40 seconds duration, mostly showing the esophagocardiac junction, were created and shown to 100 endoscopists using a video projector. The participating endoscopists completed a questionnaire regarding their clinical experience and rated the reflux esophagitis as shown in the video clips using the modified LA classification system. Agreement was assessed employing kappa (kappa) statistics for multiple raters. The kappa-value for all 91 endoscopists was 0.094, with a standard error of 0.002, indicating poor interobserver agreement. The endoscopists showed the best agreement on diagnosing grade A esophagitis (0.167), and the poorest agreement when diagnosing grade M esophagitis (0.033). The kappa-values for the diagnoses of grades N, M, and A esophagitis on identical video pairs were 0.275-0.315, with a standard error of 0.083-0.091, indicating fair intraobserver reproducibility among the endoscopists. The study results consistently indicate poor agreement regarding diagnoses as well as fair reproducibility of these diagnoses by endoscopists using the modified LA classification system, regardless of age, type of practice, past endoscopic experience, or current workload. However, grade M reflux esophagitis may not necessarily be irrelevant, as it may suggest an early form of reflux disease or an entirely new form of reflux esophagitis. Further research is required to elucidate the pathophysiological basis of minimal change esophagitis.

Background: The usefulness of the anatomy-function-pathology (AFP) score was examined to evaluate its prediction of recurrence after laparoscopic fundoplication for erosive reflux esophagitis., Methods: Of the patients undergoing laparoscopic fundoplication for erosive reflux esophagitis of Los Angeles classification grade A or higher from December 1994 to December 2004, 107 who underwent preoperative barium esophagogram, pH monitoring, and endoscopy were selected as subjects. The AFP score was calculated by A, F, and P factor grades of the AFP classification. By comparing patients with and without recurrence, the usefulness of the AFP score for predicting recurrence was examined., Results: Reflux esophagitis recurred in seven patients. No significant difference in age, sex, or A or F factor was observed between the groups, whereas a significant difference was observed in the P factor (p = 0.008). On the other hand, the mean AFP score in the recurrence group was 16.9 +/- 5.3, whereas that in the nonrecurrence group was 8.9 +/- 5.3 (p = 0.0021). Among the patients with a score of 17 points or more (n = 23), recurrence was found in 6 patients (26%). On the other hand, among the patients with a score lower than 17 points (n = 84), recurrence was found in 1 patient, but not in the remaining 83 patients (1%). Sensitivity was thus 85.7% (95% confidence interval [CI], 42.1-99.6), and specificity was 83% (95% CI, 74.2-89.8). The positive predictive value was 26.1% (95% CI, 10.2-48.4), and the negative predictive value was 98.8% (95% CI, 93.5-99.9). Multiple logistic regression analysis was performed, and receiver operating characteristics curves were obtained. The area under the curve for the AFP score was 0.8457, whereas that for the P factor was 0.7907 (p = 0.0045), suggesting that the AFP score may more accurately predict recurrence than the P factor., Conclusion: The AFP score may be useful for predicting postoperative recurrence. If surgery is performed when the AFP score is lower than 17 points, the likelihood of postoperative recurrence is expected to be very low.

Objective: This study was aimed to evaluate the correlation between dysphagia, detected by nursing staff in a brief interview and endoscopic findings in reflux esophagitis., Patients and Methods: A total of 8,031 Japanese subjects without medication for gastrointestinal disease were briefly asked about the presence of heartburn, dysphagia, odynophagia, and acid regurgitation by nursing staff before endoscopy for assessment of esophagitis utilizing the Los Angeles Classification., Results: The grade of endoscopic esophagitis was not equivalent to symptoms of dysphagia in 8,031 subjects. We evaluated the characteristics of subjects who complained of only dysphagia. Univariate analysis indicated that non-smoking, and non-drinking females were associated with a higher risk for dysphagia, and multivariate analysis indicated the gender was associated with dysphagia. There was no association of dysphagia with herniation and distribution of age., Conclusion: This study indicated that dysphagia was not equivalent to the endoscopic findings according to a brief interview by nursing staff and that dysphagia might be more common in females and those who do not smoke or drink.

Children and adolescents with symptomatic gastroesophageal reflux disease (GERD) and erosive esophagitis (EE) of grade >/=2 (n=45) or nonerosive esophagitis (NEE) (n=45) were assessed to determine the relationship between presenting symptoms, esophagitis severity, and patient age. Overall, regurgitation/vomiting, abdominal pain, and cough were the most frequent symptoms. The prevalence and severity of anorexia/feed refusal was significantly greater in EE versus NEE children; this symptom was also significantly more prevalent in younger (1-5 years) children (both NEE and EE groups) compared to older children. Cough was significantly less severe in NEE adolescents than in younger children. Cough, anorexia/feed refusal, and regurgitation/vomiting were more severe and heartburn was less severe in EE children aged 1-5 years compared with older patients. In conclusion, GERD in children manifests differently than that in adults and symptoms vary with patient age. Symptoms were not predictive of presence or lack of mucosal damage.

Minimal change esophagitis is commonly accepted as part of the spectrum of reflux esophagitis in Japan as well as in many reflux esophagitis classification systems. However, the Los Angeles system excludes minimal changes as a sign of reflux esophagitis because of low interobserver agreement. The high prevalence of minimal change esophagitis suggests that many endoscopists can recognize such findings in their patients' esophagi. However, we do not have a clear definition of minimal changes, which requires proven interobserver agreement, histological evidence, and response data to therapeutic intervention. Furthermore, erythematous changes (red ones) and acanthotic changes (white ones) are not distinguished in the definition of minimal change used in Japan. It is time to clarify such issues.

Background: The Savary-Miller, the Los Angeles, and the MUSE (metaplasia, ulcer, stricture, erosion) scoring systems have been developed to assess esophageal lesions related to GERD. Interobserver agreement for these systems was compared, with particular reference to the experience of the endoscopist., Methods: By using videoendoscopes, videotapes were made of the gastroesophageal junction of 60 patients who presented with symptoms suggestive of GERD. The Savary-Miller, the Los Angeles, and the MUSE systems were used to score all video clips by 9 endoscopists who were subgrouped by level of experience (3 levels, 3 endoscopists per level). Agreement was assessed by using weighted kappa statistics (kappa)., Results: The Savary-Miller scoring system revealed moderate agreement for the experienced group (kappa=0.41) but performed poorly when applied by inexperienced raters (kappa=0.16). The Los Angeles system was most reproducible in all subgroups, irrespective of the level of experience (kappa=0.49 to 0.65). The MUSE scoring system was highly similar to the Los Angeles scoring system with respect to erosions and, in addition, allowed assessment of complications of GERD., Conclusions: The Los Angeles and the MUSE scoring systems are most reliable for the assessment of erosions caused by GERD. Because of low reliability, use of the Savary-Miller scoring system is not recommended. For all scoring systems, interobserver agreement varies with the level of experience in the performance of upper endoscopy.

Objective: The aim of this study was to validate the endoscopic findings against histologic features of the distal esophageal mucosa for the diagnosis of reflux esophagitis in infants., Methods: The data records of 167 patients (88 M; 79F) aged 38-364 days, referred for investigation of reflux esophagitis, between January 1995 and December 2000 were retrospectively reviewed. The association between nominal (presence or absence of esophagitis) and ordinal (grades of esophagitis) variables was analyzed through a correlation between the results of endoscopic findings and histology., Results: Endoscopy when compared with histologic analysis had a sensitivity of 45%; specificity of 71%; positive and negative predictive value of 89% and 21% respectively; and accuracy of 50%. Additionally, this study demonstrated that there was a poor correlation between endoscopic and histologic findings when endoscopy was normal or when endoscopic grade I esophagitis was observed (p = 0.10). Normal esophageal appearance failed to identify 79.2% of patients with histologic esophagitis. Conversely, amongst patients with endoscopic grade I esophagitis, 12.1% had normal histology., Conclusions: We concluded that whilst endoscopy had a specificity of 71%, it did not attain an acceptable range of sensitivity (45%) to justify performing an endoscopy without biopsy, as many true cases of esophagitis would not be detected; and that the presence of grade I (non-erosive) esophagitis at endoscopy did not increase the value of the test in predicting histologic abnormality.

Background and Purpose: Reflux esophagitis of Los Angeles grade A or B is more common than grades C and D disease among Taiwanese. This study compared the efficacy of esomeprazole 40 mg and omeprazole 20 mg for starting on-demand therapy for grade A and B reflux esophagitis., Methods: 100 patients with grade A and B reflux esophagitis were randomized to receive either esomeprazole 40 mg once daily (n = 50) or omeprazole 20 mg once daily (n = 50) for the first 4 weeks. Sustained symptomatic response (SSR) was defined as freedom from symptoms for the last 7 days of the 4-week treatment duration. On-demand therapy was used for the next 4 weeks in patients with SSR; patients without SSR continued with the same proton pump inhibitor regimen. Patients were asked to record their daily severity of acid regurgitation (AR) and heartburn (HB). Medication usage during on-demand therapy was recorded., Results: Forty six patients in the esomeprazole group and 45 patients in the omeprazole group completed the study protocol. The rate of SSR was higher in the esomeprazole group than in the omeprazole group (per-protocol: 73.9% vs 51.1%, p < 0.05; intent-to-treat: 68% vs 46%, p < 0.05). The symptomatic scores for AR and HB were similar between patients taking medication continuously and those taking medication on-demand with both esomeprazole and omeprazole. For patients starting on-demand therapy, the total number of tablets used during 4 weeks was lower in the esomeprazole group than in the omeprazole group (13.5 vs 18.5, p < 0.05)., Conclusions: In patients with grade A and B reflux esophagitis, esomeprazole 40 mg was more effective than omeprazole 20 mg for the initiation of on-demand therapy.

Background: Recent studies have shown that the number of patients with reflux esophagitis is increasing in Japan, but the prevalence and risk factors associated with reflux esophagitis in Japanese patients are not well defined., Methods: By using all endoscopic records in the Katta General Hospital from April through to September 1999, we identified 392 patients. We examined the Los Angeles classification, peptic ulcer, gastric mucosal atrophy, hiatal hernia and other medical variable factors for their contribution to esophagitis in the patients., Results: Patients (13.8%) were diagnosed as having reflux esophagitis with a mucosal break. In a multivariate analysis, reflux esophagitis was associated with hiatal hernia (odds ratio (OR) 2.276, 95% confidence interval (CI) 1.164-4.450), with patients over 65 years of age (OR 2.521, 95% CI 1.238-5.134) and the open type of gastric mucosal atrophy (OR 0.420, 95% CI 0.225-0.785). There was no significant difference between esophagitis and Helicobacter pylori infection and peptic ulcer., Conclusions: We observed that age, hiatal hernia and a lower rate of gastric mucosal atrophy were associated with the proportion of mucosal breaks accompanying esophagitis.

Gastroesophageal reflux disease (GERD) is a common disease increasing in incidence and prevalence in the industrialised countries. It is a chronic disease with a large spectrum of clinical manifestations. The leading symptom is heartburn, however the disease may also present with extraesophageal symptoms or stay asymptomatic. Motility disorders of the upper GI tract with the key feature of impaired LES are the cause for pathologic gastroesophageal reflux in the terminal esophagus. The relationship of H. pylori infection with GERD is part of the current discussion. The Savary Miller classification for grading of refluxesophagitis is now proposed for substitution by the Los Angeles classification for the assessment of erosive lesions. Besides complications such as bleeding or strictures the main risk is the development of Barrett esophagus and adenocarcinoma. Proton pump inhibitors are the therapy of choice for healing as well as in longterm therapy and prophylaxis. New endoscopic interventional therapies for treatment of GERD and related diseases should be used only in controlled studies.

A new endoscopic classification of reflux esophagitis was proposed in Los Angeles in 1994(LA classification). A mucosal break was defined as 'an area of slough or an area of erythema with a discrete lined demarcation from the adjacent or normal looking mucosa'. Reflux esophagitis is divided into four grades according to the severity of its mucosal break. We can find a minimal change during endoscopy which is not a mucosal break but is histologically or chromographically reflux esophagitis. I think Los Angeles classification must include the minimal change and I propose a modification of LA classification which includes the minimal change as grade M and the esophagus without any minimal change and mucosal break as grade N.

Endoscopy is, currently, the initial investigation of choice for the investigation of gastroesophageal reflux disease (GERD) in clinical practice and clinical research. Erosion severity is predictive of a patient's response to therapy and of the likelihood of relapse after therapy. It is, therefore, important to grade the severity of erosive reflux esophagitis, particularly in the context of clinical trials. The Savary-Miller endoscopic classification system is used widely but usage and interpretation are very variable. The "MUSE" (metaplasia [M], ulceration [U], stricturing [S] and erosions [E]) classification provides clear definitions of the relevant endoscopic features, and it is based on a standardized report form, which allows the endoscopist to make a clear record of esophagitis severity. Recent studies confirm that endoscopists can identify erosions or mucosal breaks, ulcers, strictures, and metaplasia reproducibly. The "L.A." (Los Angeles) classification describes four grades of esophagitis severity (A to D), based on the extent of esophageal lesions known as "mucosal breaks," but it does not record the presence or severity of other GERD lesions. Thus, for patients with "complicated" reflux disease, the "MUSE" classification offers a more comprehensive description of esophagitis severity. Endoscopy is not universally applicable: 40 to 60 percent of patients with typical reflux symptoms do not have esophageal erosions and are now considered to have "endoscopy negative reflux disease" (ENRD). Thus, endoscopy is not the final arbiter as to a diagnosis of reflux disease, and it is not, therefore, a necessary prerequisite to therapy. Endoscopy is indicated at first presentation for patients with alarm symptoms referable to the upper gastrointestinal tract. It has also been proposed that all patients with chronic GERD should have a "once-in-a-lifetime" endoscopy; in the absence of Barrett's esophagus or other complications, no follow-up is required unless the patient's symptoms change significantly. A surveillance program with multiple biopsies should be instituted if there is evidence of Barrett's esophagus. Endoscopic evaluation should document the presence and extent of esophageal erosions using the L.A. or MUSE classification systems; complications should also be documented and may be recorded using the MUSE classification. Non-erosive changes such as erythema may be ignored on the basis of present evidence, and there are no clear data to support the use of endoscopic biopsies for the diagnosis of GERD.

Objective: To compare and contrast the efficacy and tolerability of a proton pump inhibitor, pantoprazole, to that of an H2 antagonist, ranitidine, in the treatment of patients with mild to severe reflux esophagitis., Background: Reflux esophagitis is a common illness affecting 5-10% of the world's population. Acid reflux plays a major role in the disease's genesis, as do esophageal and gastric motility disturbances., Methods: 315 patients (intent to treat) with endoscopically confirmed reflux esophagitis (Savary-Miller (SM) stages II and III) were recruited to the study by 46 mexican investigators in nine centers. Patients received either pantoprazole 40 mg once daily or ranitidine 150 mg twice daily in this double blind, randomized, parallel group study. Patients not achieving complete endoscopic healing after four weeks of therapy received an additional four weeks of treatment. Drug tolerability was assessed by adverse event reporting during the study., Results: After four weeks pantoprazole therapy, 81% of patients with SM II and 67% of the patients with SM III were healed; in contrast ranitidine healed only 67 and 30% of the patients respectively, all results expressed on an per-protocol basis. After eight weeks therapy the healing rates for pantoprazole group increased to 94% and the ranitidine group to 74% (p = 0.001). The incidence of adverse events was less than 2% in both treatment groups, thus both therapies were found to be well tolerated., Conclusions: Pantoprazole is superior to ranitidine in the treatment of mild to severe reflux esophagitis and is equally well tolerated.

Endoscopic diagnosis and classification of reflux esophagitis were described, which is gradually increasing in number in Japan. It is important to diagnosefor a type, grade, and degree, hearing stage and others (stenosis, Barrett's esophagus etc), when we perform endoscopic examination for reflux esophagitis patients. Iodine staining should be applied as far as possible. Los Angeles system for classification of reflux esophagitis was proposed at the 10th World Congress of Gastroenterology in October 1994. As for LA classification, reflux esophagitis is classified to 4 grade, from A to D, predicated on the grade of mucosal break. For any doctors, this is easy to apply to the classification of reflux esophagitis and the diagnosis of classification will be equal. The Japanese Society of Disease of Esophagus also proposed the new classification of reflux esophagitis, that is JSED '96 Classification. This classification contains grade 0, which indicate no reflux esophagitis and grade 1, which indicate the discoloring type of esophagitis. Another 3 grades are based on the length of esophagitis and also occupation on circumference of esophagus. This will be suitable for the Japanese reflux esophagitis and can be changed to LA classification easily. The International Society of Disease of Esophagus proposed AFP classification which is useful to decide the application to surgical treatment. The detail of these classifications and the important points on the endoscopic diagnosis of reflux esophagitis were mentioned in this paper.

Objectives: The therapeutic approach to gastroesophageal reflux disease (GERD) in intellectually disabled individuals has not been studied extensively. So far, only low response rates to medical and surgical therapy of GERD have been reported. However, the efficacy of proton pump inhibitors, to date the most effective medical therapy for GERD, has never been evaluated in this population. Our purpose, therefore, was to study the effect of omeprazole on healing and symptom relief in the intellectually disabled., Methods: The treatment scheme was as follows: omeprazole 40 mg was given once daily (o.d.) as a healing dose for 3 months, and omeprazole 20 mg o.d. was given as a maintenance dose for another 3 months, to intellectually disabled subjects with endoscopically proven esophagitis, grades I-IV, according to Savary-Miller classification. After 3 and 6 months, the result of this treatment was evaluated by symptom scoring and/or endoscopy. In case of relapse, the dose was increased., Results: At the first endoscopy, 40 of 107 patients (37%) had grade I, 36 (34%) grade II, 18 (17%) grade III, and 13 (12%) grade IV esophagitis. In 92 of 104 patients (88%), the treatment scheme was effective in healing the esophagitis and keeping patients in remission, independent of the severity of esophagitis. In 11 of 104 (11%) patients, a symptomatic relapse was observed after the dose was decreased to 20 mg o.d. However, all of these patients became symptom free again after the dose was increased to 40 mg o.d., and all were healed endoscopically at the end of the study. One (1%) patient needed omeprazole 60 mg o.d. for healing, but in this patient, no relapse was seen while on a maintenance dose of omeprazole 40 mg o.d. Marked improvement of persistent vomiting, hematemesis, regurgitation, food refusal, iron deficiency anemia, and depressive symptoms was seen at the end of the study., Conclusions: This study indicates that omeprazole is highly effective for all grades of esophagitis in the intellectually disabled. The dose needed to maintain them in remission can be titrated according to the reflux symptoms.

Objectives: Very few epidemiological data on reflux esophagitis in Chinese are available in the literature., Methods: To evaluate the incidence of reflux esophagitis, upper gastrointestinal endoscopies were performed on 2044 patients (male 1266, female 778; age range 16-82 yr) during a 6-month period., Results: The overall incidence of reflux esophagitis was 5%, and most of the patients (86.3%) had a mild grade of esophagitis. Hiatal hernia was found in 44 patients (2.2%); those patients were significantly older than those without hiatal hernia (60.3 +/- 10.8 vs. 49.4 +/- 12.1 yr, p < 0.05). Patients with symptoms suggesting gastroesophageal reflux (acid regurgitation, heartburn, and belching) had higher incidence of esophagitis (22.9%, 22.5%, and 24.7%, respectively). The body mass index was significantly higher in patients with esophagitis than in those without esophagitis (25.7 +/- 3.1 vs. 24.0 +/- 3.6, p < 0.05). The male:female ratio for esophagitis was 5.6:1. No esophagitis was found in patients who were less than 21 yr old. However, there was a difference in age group distribution for the incidence of esophagitis. The habit of coffee or tea drinking does not contribute to the development of esophagitis., Conclusions: Based on the results of this study, the incidence of endoscopic reflux esophagitis among the Chinese is 5%, which is lower than in Western countries.

This study is based on entry criteria of visual findings of the upper gastro-intestinal fibre-optic endoscopy performed on 100 patients suffering from acid peptic disease (dyspepsia). The diagnostic criteria and grading of reflux oesophagitis advocated by Savary and Miller have been adopted. Reflux oesophagitis was found in 43 cases having grade I oesophagitis in 48.84%, grade II in 32.56%, grade III in 14.00% and grade IV in 4.60% cases. Reflux oesophagitis was associated with hiatus hernia in 23.26%, chronic gastritis in 9.30% of cases. The age varied from 16-80 years with almost equal incidence of male and female, and the severity of the disease increased with the advancement of age. Endoscopy is advised in every case of dyspepsia before any treatment is initiated.

Following failure of conventional therapy for reflux oesophagitis, 15 children were treated with omeprazole 20 mg daily for a period of up to three months initially. Treatment resulted in a marked symptomatic improvement as measured by incidence of pain, vomiting, dysphagia and haematemesis. Four children failed treatment and required fundoplication. No complications from the use of omeprazole were recorded and some children have continued long-term treatment.

Background: Patients with reflux esophagitis have a high rate of relapse within one year after therapy is discontinued., Methods: We enrolled 175 adults with endoscopy-confirmed reflux esophagitis in a prospective study comparing five maintenance therapies. All the patients were initially treated with omeprazole (40 mg orally once a day) for four to eight weeks, and healing was confirmed by endoscopy. Participants were then stratified according to their initial grade of esophagitis and randomly assigned to 12 months of treatment with one of the following: cisapride (10 mg three times a day), ranitidine (150 mg three times a day), omeprazole (20 mg per day), ranitidine plus cisapride (10 mg three times a day), or omeprazole plus cisapride. Endoscopy was repeated after 6 and 12 months of treatment; the endoscopists were blinded to the treatment assignments. Remission was defined as the absence of esophageal lesions on scheduled or unscheduled follow-up endoscopy., Results: In an intention-to-treat analysis, the numbers of patients in continued remission at 12 months were 19 of 35 (54 percent) in the cisapride group, 17 of 35 (49 percent) in the ranitidine group, 28 of 35 (80 percent) in the omeprazole group, 23 of 35 (66 percent) in the ranitidine-plus-cisapride group, and 31 of 35 (89 percent) in the omeprazole-plus-cisapride group. Omeprazole was significantly more effective than cisapride (P = 0.02) or ranitidine (P = 0.003), and combination therapy with omeprazole plus cisapride was significantly more effective than cisapride alone (P = 0.003), ranitidine alone (P < 0.001), or ranitidine plus cisapride (P = 0.03). Ranitidine plus cisapride was significantly better than ranitidine alone (P = 0.05)., Conclusions: For maintenance treatment of reflux esophagitis, omeprazole alone or in combination with cisapride is more effective than ranitidine alone or cisapride alone, and the combination of omeprazole and cisapride is more effective than ranitidine plus cisapride.

Fifteen patients with reflux esophagitis were treated surgically from July 1990 to April 1994. We evaluated these patients using the anatomic-functional-pathologic (AFP) classification both prior to and following the operation. An objective index for surgical outcome was devised. By using the grades Ai, Fj, and Pk, the i2 + j2 + k2 score was determined. The scores ranged from 3 to 22 (mean 9.1 +/- 5.4) prior to the operation. Postoperatively, 12 (80%) of 15 patients showed a complete recovery with a numerical score of 0, and their symptoms also disappeared. The scores of these 12 patients prior to the operation ranged between 3 and 11. However, the other 3 patients did not exhibit a complete recovery. Their scores prior to the operation ranged between 17 and 22, and the symptoms in 2 of these 3 patients persisted following the operation. These results suggest that surgical treatment for reflux esophagitis can be expected to be successful if the preoperative AFP score is less than 11.

The factors predisposing to the development of Barrett's esophagus in patients with gastroesophageal reflux disease are unclear. We compared symptoms, esophageal acid and alkaline exposure (pH < 2, < 3, < 4, and > 7), lower esophageal sphincter resistance, esophageal clearance function, the gastric secretory state, gastric emptying, and duodenogastric reflux in 15 patients with Barrett's esophagus with 24 patients with esophagitis and with 22 normal subjects. Compared with patients with esophagitis, patients with Barrett's esophagus had less heartburn and regurgitation but had an increased frequency and duration of reflux episodes and percent time pH less than 2, less than 3, less than 4, and pH greater than 7 on ambulatory 24-hour esophageal pH monitoring. This was associated with a decreased lower esophageal sphincter resistance, a decreased contraction amplitude in the distal area of the esophagus, an increased frequency of nonperistaltic contractions and contractions less than 30 mm Hg on 24-hour ambulatory esophageal motility monitoring, increased basal and stimulated gastric acid secretion, and a higher prevalence of excessive duodenogastric reflux. These data show that despite less symptoms patients with Barrett's esophagus have a markedly increased esophageal acid and alkaline exposure compared with patients with esophagitis. This appears to be because of persistent reflux of highly concentrated gastric acid and duodenal contents across a mechanically defective lower esophageal sphincter in combination with inefficient esophageal clearance function.

Sucralfate (Sc) suspension 6 g/day and ranitidine (Rn) tablets, 150 mg, were compared in 125 patients in a double-blind, multicenter, endoscopically controlled trial in the treatment of reflux esophagitis. Inclusion criteria were symptomatic reflux (number and severity of attacks) and endoscopic evidence of esophagitis (grades 1 to 4). Clinical assessments were performed on entry, and at 4 and at 8 weeks, and endoscopy was repeated at 8 weeks. Sc suspension and Rn placebo or Sc placebo and Rn tablets were taken on waking and immediately before retiring at night. Of the 125 patients, 27 were withdrawn because of default (Rn = 4; Sc = 14), noncompliance (Rn = 1; Sc = 2), or the development of congestive cardiac failure (Rn = 1), diarrhea (Rn = 1; Sc = 1), nausea (Sc = 1), constipation (Sc = 1), and hematemesis (Sc = 1). Analysis was performed on the remaining 98 patients, 43 of whom had been treated with Sc and 55 with Rn. Heartburn, acid regurgitation, epigastric pain, dysphagia, and chest pain were relieved in 34% vs 40%, 67% vs 72%, 71% vs 57%, and 86% vs 63% for Sc and Rn, respectively. There was no significant difference between the two groups. Endoscopic healing occurred in 47% of the Sc- and in 31% of the Rn-treated patients (chi 2 = 2.50), and healing or improvement was noted in 81% of the Sc- and 64% of the Rn-treated patients. This difference approached statistical significance (chi 2 = 3.73). There was no obvious endoscopic benefit in 8 of the 43 and 20 of the 55 patients in the groups treated with Sc and Rn, respectively. Although the findings with sucralfate and ranitidine in patients with reflux esophagitis completing the trial suggest a benefit of these agents, the absence of a placebo control group and the high default rates, particularly for those receiving sucralfate, preclude any firm conclusions as to relative or specific efficacy of these agents in this condition.

Endoscopy reveals that the lesions of reflux esophagitis are red and white spots and streaks. The red lesions are thought to reflect local inflammatory alterations with or without partial necrosis of the squamous epithelium, while white lesions represent complete necroses of the squamous epithelium with fibrin deposits. Fifty-nine patients with reflux esophagitis and red lesions (n = 23) or white lesions (n = 36) underwent endoscopically controlled biopsy of selected particles. Histologic analysis confirmed the hypothesis that white lesions are nearly always necroses involving all layers of the squamous epithelium with fibrin deposits (and rarely epithelial hyperplasia), while red lesions are caused by local granulocytic inflammation or granulation tissue with partial reepithelialization. These results suggest that reflux esophagitis Savary Stages I and II can be rationally subclassified into reflux esophagitis with red spots (Stage Ia), white spots (Stage Ib), red streaks (Stage IIa), and white streaks (Stage IIb).

The place of conservative procedures and resection in the surgical treatment of complicated peptic oesophagitis is still controversial. In order, to propose decisional criteria for the therapeutic choice, we reviewed 102 patients operated on from 1979 to 1987, with strictures (n = 61), Barrett's oesophagus (n = 27) or previous surgical treatment (Heller, resection, repeated fundoplications, n = 33). Patients were classified into 3 grades: a) The first group consisted of low, short, dilatable and reversible strictures without Barrett's, oesophagus, treated by dilatations and fundoplication (n = 36). b) The second group consisted of Barrett's oesophagus, peptic oesophagitis after surgery and acquired short oesophagus with or without dilatable stricture, treated by Roux-en-Y duodenal diversion (n = 60) with dilatation in case of stricture. Collis-Nissen's procedure could be used for such cases, but conservative procedures via a thoracic approach has no indications for us. c) Group 3 was treated by resection (colonic interposition when possible) and consisted of peptic ulcers, extensive sinuous and poorly dilatable strictures or suspected cancer (n = 9). Decisional factors were: stricture (size, height, level, response to preoperative dilatation), ulcer (hemorrhagic or suspicion of carcinoma), acquired short oesophagus, Barrett's oesophagus, previous surgical treatment. Intensity or type of reflux was not decisional. With this policy, only 3 recurrences occurred, all after reposition for stricture, successfully treated by resection or duodenal diversion. The low recurrence rate confirms the decisional value of the chosen criteria.

Both antacids and H2 receptor antagonists have a potential role in treating peptic oesophagitis associated with acid reflux. The aim of this study is to assess the efficacy and tolerability of famotidine and alginate-antacid in children with endoscopically documented peptic oesophagitis. We compared clinical, endoscopic and histological response to alginate-antacid (1 tablet to be chewed 30 min after each meal and at bed time) or famotidine (1 mg/kg before supper at 7 pm) in 49 children (mean age 9 years, 34 males). Twenty-four of them were randomly allocated to alginate-antacid treatment (group A), twenty-five to famotidine (group B). Both treatments were protracted for six months and endoscopy was then repeated. Symptoms disappeared in 43.4% and improved in 47.8% of children of group A and disappeared in 91.6% of those of group B (p less than .05). Mean time for symptom disappearance was 17 weeks for group A and 5 weeks for group B (p less than .01). After six months, at endoscopy oesophagitis was healed in 43.4% in group A and in 41.6% of group B, the difference between the two groups was not significant, however the improvement of endoscopic grades induced by famotidine was significantly better (p less than .05). Histology showed a healed peptic oesophagitis in 52.2% of the children in group A and in 70.8% of group B (p less than .001). No toxicity was observed with either treatment. We conclude that famotidine is superior to alginate-antacid in treating peptic oesophagitis associated with acid reflux, since it induces a better symptomatic response and a greater improvement of endoscopic lesions.

In 42 patients (25 men, 17 women, mean age 62 years) with severe erosive or ulcerative oesophagitis not responding to H2-receptor antagonist treatment over at least 3 months and ineligible for surgery, omeprazole was administered at an initial dose of 40 mg/day, subsequently reduced to 20 mg after healing of the lesions. Patients had monthly clinical, endoscopic, histological and laboratory assessment over the healing period, then were reevaluated 3-monthly over one year, then 6-monthly, during the maintenance treatment. Stages of oesophagitis were based on the Savary-Miller classification, modified for stage I (erosions must be present). With 40 mg omeprazole, healing was observed in 71%, 83% and 90% of the patients after 1, 2 and 3 months of treatment, respectively. After one month of treatment, a complete healing was less frequently observed in patients with stage IV oesophagitis pre-trial (55%) than in the patients with stages I, II and III pre-trial (90%) (p less than 0.05). Ninety per cent of the patients healed at one month were asymptomatic whereas 50% of the patients with incomplete healing still had symptoms, most often dysphagia, rarely heartburn. Maintenance treatment with 20 mg was sufficient in most patients, with a probability of remaining healed of 69% from 9 to 24 months after starting this dosage. In 9 patients with Barrett's oesophagus, the lengths of the circumferential metaplasia were found to be reduced after one year of treatment compared to pre-trial lengths (p less than 0.005). There was no further significant reduction of length after 2 years of treatment. Fasting gastrin was increased in most of the patients, although great inter-patient variability was observed; 50% of the patients had levels not exceeding 5 times the upper limit of normal. There was no consistent increase of enterochromaffin-like cell density in 29 patients investigated up to nearly 2 years of omeprazole administration. The treatment was well tolerated. By inducing a profound and sustained inhibition of acid secretion, as confirmed by pH monitoring, omeprazole promotes healing of the lesions of severe oesophagitis and prevents recurrence of lesions and symptoms. Omeprazole is therefore a valuable treatment for patients ineligible for surgery, particularly in the elderly.