Abstracts
Abdominal syndromes
Gastroenterologists use different definitions of irritable bowel syndrome and upper dyspepsia, and the different definitions select different populations with the syndromes.
The following 3 definitions describe subjects with symptoms occurring together more often than could be expected by chance:
1. Subjects stating that they often experience both abdominal pain and distension and, additionally, either borborygmi or altering stool consistency. This combination occurred with a prevalence of 3.2% among men and 7.5% among women;
2. Subjects stating that they experience all of the following three symptoms: abdominal pain, heartburn, and acid regurgitation. This combination occurred with a prevalence of 1.3% among men and 0.8% among women;
3. Subjects stating that they often experience both nausea and abdominal pain. This combination occurred with a prevalence of 0.9% among men and 3.6% among women.
These definitions are suggested as standards for irritable bowel syndrome, upper dyspepsia-heart burn type and upper dyspepsia-nausea type, respectively.
Kay L & Jorgensen T: Redefining abdominal syndromes. Results of a population-based study. Scand J Gastroenterol, 1996 May, 31:5, 469-75.
Acid perception
Acid perception
Contrasted the psychosocial profiles of patients with gastro-oesophageal reflux disease whose symptoms correlate well with acid reflux against those whose symptoms do not.
Symptom-negative patients displayed significantly higher levels of trait anxiety and hysteria. The adequacy of their social support structures was significantly lower. No difference in daily hassles or uplifts was found.
Significant psychosocial differences are noted in patients with poor symptom-reflux correlation. These differences may help explain the aetiology of such patients' symptoms.
Johnston BT et al., Acid perception in gastro-oesophageal reflux disease is dependent on psychosocial factors. Scand J Gastroenterol, 1995 Jan, 30:1, 1-5.
Acidity
Distal esophageal pH less than 4 is frequently seen during meal ingestion in 24-hr ambulatory pH monitoring for the diagnosis of gastroesophageal reflux disease (GERD). Furthermore, exclusion of meal periods can eliminate meal-time pH variabilities without affecting postprandial acid exposure and improve the diagnosis of GERD.
Wo-JM; Castell-DO: Exclusion of meal periods from ambulatory 24-hour pH monitoring may improve diagnosis of esophageal acid reflux. Dig-Dis-Sci. 1994 Aug; 39(8): 1601-7
Alkali secretion
Recent human studies suggest that oesophageal HCO3- secretion, in conjunction with salivary HCO3- secretion and secondary oesophageal peristalsis, is important for the protection of oesophageal mucosa from refluxed gastric contents.
Oesophageal perfusion with 10 mM HCl did not cause symptoms (nausea and heartburn), but tripled the oesophageal HCO3- output from a baseline of 51 mumol/10 cm/10 min, while doubling the rate of salivary HCO3- secretion from a median basal value of 140 mumol/10 min. Oesophageal perfusion with 100 mM HCl was associated with symptoms of nausea and heartburn in all subjects.
Oesophageal acidification stimulates both salivary and oesophageal HCO3- secretion, responses which may be protective to the oesophageal epithelium.
Brown CM: Effect of topical oesophageal acidification on human salivary and oesophageal alkali secretion. Gut, 1995 May, 36:5, 649-53.
Antacids
Antacids are a useful remedy for the common complaint of indigestion but if indigestion persists, the patient should seek medical advice and look assess their life-style.
Antacids should be taken in response to symptoms, usually after meals, to counter the surge of acid produced by the body to digest food.
Antacids can interfere with drug absorption, so patients on other medications should ask a pharmacist's advice on the timing of their antacid dose. Liquid or soluble preparations act faster than tablets.
Sinclair-A: Remedies for common family ailments: 1. Indigestion and heartburn. Prof-Care-Mother-Child. 1994 Jan-Feb; 4(1): 23-4
Asthma & heartburn
Determined the prevalences of symptomatic gastroesophageal reflux (GER), reflux-associated respiratory symptoms (RARS), and reflux-associated beta-agonist inhaler use in asthmatics.
Among the asthmatics, 77%, 55%, and 24% experienced heartburn, regurgitation, and swallowing difficulties, respectively.
At least one antireflux medication was required by 37% of asthmatics. None of the asthma medications were associated with an increased likelihood of symptomatic GER.
The questionnaire demonstrated a greater prevalence of GER symptoms, RARS, and reflux-associated inhaler use in asthmatics. This excessive inhaler use may explain how GER indirectly causes asthma to worsen.
Field SK et al., Prevalence of gastroesophageal reflux symptoms in asthma. Chest, 1996 Feb, 109:2, 316-22.
Beverages & heartburn
Although many beverages produce heartburn, the relationship between the acidity and osmolality of beverages and heartburn is unclear.
Among 17 citrus drinks and juices, titratable acidity correlated with reported heartburn scores.
Soft drinks had the lowest pH readings of any beverages studied, and decreasing pH among soft drinks was correlated with reported heartburn scores.
Alcoholic beverages (wines and beer), coffee, and (to a lesser extent) tea were associated with significant amounts of reported heartburn when compared with water.
Milk was also associated with a modest amount of reported heartburn that was related to its fat content.
Osmolality of beverages was unrelated to reported heartburn.
High titratable acidity of citrus drinks and juices and low pH of soft drinks are associated with more reported heartburn. Findings provide a foundation for dietary advice in patients with heartburn and reflux esophagitis.
Feldman M & Barnett C: Relationships between the acidity and osmolality of popular beverages and reported postprandial heartburn. Gastroenterology, 1995 Jan, 108:1, 125-31.
Radiation & heartburn
Radiation-induced esophagitis can cause substantial morbidity. Experiments in lab animals have shown that pretreatment with indomethacin protects the esophagus from radiation damage.
Acute radiation injury to the esophagus is observed in approximately half the patients receiving radiation therapy and can result in substantial morbidity.
Soffer-EE et al: Morphology and pathology of radiation-induced esophagitis. Double-blind study of naproxen vs placebo for prevention of radiation injury. Dig-Dis-Sci. 1994 Mar; 39(3): 655-60.
Running & heartburn
To investigate the belief that running causes diarrhoea and gastroesophageal reflux.
The runners ate more fibre and had more frequent bowel movements which were more often loose or urgent. They had less constipation but there was no difference in the use of laxatives or the prevalence of the irritable bowel syndrome. Although most runners tried to empty their bowels before running, the urgent need to have a bowel movement was still the most common reason for a runner to stop during a run. Heartburn, vomiting and bloating were more common when not training while retching, stitches and fecal incontinence were more common when running. Few runners ate before running and upper gastrointestinal symptoms while running were rare.
Therefore, lower gastrointestinal symptoms may be caused by running or the running lifestyle. Upper gastrointestinal symptoms are not due to running alone.
Sullivan-SN et al: Does running cause gastrointestinal symptoms? A survey of 93 randomly selected runners compared with controls. N-Z-Med-J. 1994 Aug 24; 107(984): 328-31.
Chiropractic & heartburn
Determined the prevalence of indigestion and mid-back pain in persons seeking chiropractic care.
57% of patients reported indigestion infrequently or more and 71% reported mid-back pain during the previous 6 months. Forty-six percent experienced both symptoms during this time. Of these, 36% reported the symptoms together at some time. 22% of those with indigestion reported some relief after chiropractic care.
Indigestion and mid-back pain are commonly experienced in this population. A person with indigestion is more likely to report mid-back pain. Relief of indigestion by manipulation is more common among those who report mid-back pain.
Bryner P & Staerker PG: Indigestion and heartburn: a descriptive study of prevalence in persons seeking care from chiropractors. J Manipulative Physiol Ther, 1996 Jun, 19:5, 317-23.
Cigarette smoking & heartburn
Reassessed the effect of cigarette smoking on gastroesophageal reflux because two previous ambulatory 24-h pH monitoring studies showed equivocal results and did not relate heartburn to changes in pH reflux events.
Acid reflux was defined as a drop in intraesophageal pH to a value < 4 at 5 cm above the lower esophageal sphincter.
Cigarette smoking significantly increased the percentage time that the pH was < 4 during a 24-h period. This increased exposure occurred predominantly during the day while in the upright posture and resulted from significant increases in both reflux events and those parameters that measure acid clearance.
While smoking, the patients noted a 114% increase in daytime heartburn episodes that immediately followed a pH reflux event (3.5 to 7.5 episodes, medians; p < 0.009).
Smoking 20 cigarettes has a greater effect on acid reflux and heartburn than purported.
Kadakia SC et al., Effect of cigarette smoking on gastroesophageal reflux measured by 24-h ambulatory esophageal pH monitoring. Am J Gastroent, 1995 , 90:10, 1785-90.
Coffee & heartburn
Correlated the effects of different coffees on esophageal acid contact, heartburn, and regurgitation in patients with coffee-sensitivity.
(a) Different coffees induce variations in gastroesophageal reflux in coffee-sensitive individuals.
(b) Coffee can be treated in a manner which decreases heartburn symptoms by 75% while decreasing acid contact by only 14%.
(c) Gastroesophageal reflux and symptoms of coffee sensitivity increase with the concomitant ingestion of food.
(d) Symptoms of dyspepsia appear to be influenced by variations in both the coffee itself and characteristics of susceptible individuals.
(e) Although gastroesophageal reflux is important in the genesis of coffee-sensitivity, there must be other factors which act in concert with reflux to produce symptoms of coffee-sensitivity.
Brazer SR et al., Effect of different coffees on esophageal acid contact time and symptoms in coffee-sensitive subjects. Physiol Behav, 1995 Mar, 57:3, 563-7.
Coronary Artery Disease (CAD)
Investigated the influence of spontaneous gastro-oesophageal reflux (GOR) on symptoms and cardiac ischaemia in patients with coronary artery disease
GOR is common in patients with coronary artery disease and may be increased by drug therapy; GOR may occasionally be associated with myocardial ischaemia, but this is uncommonly symptomatic; GOR-induced pain is sometimes mistaken for angina.
These effects should be considered in the evaluation of patients with persistent chest pain despite seemingly adequate antianginal treatment.
Mehta AJ et al., Gastro-oesophageal reflux in patients with coronary artery disease: how common is it and does it matter? Eur J Gastroenterol Hepatol, 1996 Oct, 8:10, 973-8.
Cough & heartburn
Gastroesophageal reflux may be responsible for atypical symptoms such as chronic cough and hoarseness.
Evaluated and treated patients with severe gastroesophageal reflux and chronic cough or hoarseness with intensive antireflux therapy.
The response of heartburn to therapy was strongly predictive of successful therapy for the atypical symptoms. Cough and hoarseness improved in only two of the five patients with residual heartburn symptoms compared to 18 of 20 patients with no heartburn.
Only patients with no heartburn symptoms at follow-up had complete resolution of atypical symptoms.
Improvement in atypical reflux symptoms, such as chronic cough and hoarseness, is common with aggressive antireflux therapy. There are no findings on ambulatory esophageal pH monitoring that uniquely identify patients who are likely to respond to antireflux therapy.
Waring JP et al., Chronic cough and hoarseness in patients with severe gastroesophageal reflux disease. Diagnosis and response to therapy. Dig Dis Sci, 1995 May, 40:5, 1093-7.
Diabetes & heartburn
Gastrointestinal symptoms are often encountered in patients with diabetes mellitus. Symptoms may arise in any region of the alimentary tract; common symptoms are heartburn, nausea, vomiting, diarrhea, constipation, fecal incontinence, and abdominal pain.
Reviews the identification of pathophysiologic mechanisms involved in diabetic enteropathies and their complications and briefly outlines strategies to treat these symptoms.
Camilleri M: Gastrointestinal problems in diabetes. Endocrinol Metab Clin North Am, 1996 Jun, 25:2, 361-78.
GERD & heartburn
GERD (1)
GERD is a common disorder. Symptoms of reflux, such as heartburn, are due to a combination of factors: relaxation of the lower esophageal sphincter, hypersecretion of gastric acid, and resulting burning of the esophageal mucosa. Symptoms are usually classified as classic, atypical, or complicated.
Treatment approaches include dietary and lifestyle changes, reduction of acidity with use of H2 receptor antagonists, and reduction of acid secretion with use of proton pump inhibitors.
Patient motivation is an important factor in the management of gastroesophageal reflux. In rare instances, patients do not respond to medical treatment and are candidates for antireflux surgery.
Larsen RR: Gastroesophageal reflux disease: gaining control over heartburn. Postgrad Med, 1997 Feb, 101:2, 181-2, 185-7.
GERD (2)
Elucidated the long-term course of conservatively managed gastroesophageal reflux disease without H2-antagonists or omeprazole.
At follow-up 17-22 yr after referral, symptoms were less than at the time of referral in 36 of the 50 nonoperated patients (six now symptom-free), were unchanged in five, and were worse in nine patients. Medication for reflux symptoms was no longer used by 34 of the nonoperated patients.
Neither the presence of esophagitis or hiatal hernia nor the severity of symptoms at the time of referral predicted the course of the disease of the conservatively treated patients.
Severity of the symptoms declines in the long term, but pathological reflux persists in most of the conservatively treated patients. Thus, the reflux itself is not self-limiting, and therapy should be designed with this in mind.
Isolauri J et l., Natural course of gastroesophageal reflux disease: 17-22 year follow-up of 60 patients. Am J Gastroenterol, 1997 Jan, 92:1, 37-41.
GERD (3)
Symptoms suggestive of gastro-oesophageal reflux disease are very common.
Assessed the prevalence of these symptoms and factors influencing them in an unselected adult population by questionnaire.
Using daily heartburn and/or regurgitation as dominant indicators 10.3% (95% CI 12-11.7) of the responders had gastro-oesophageal reflux disease. During the past year 43% of the study group had no such symptoms. Age, overweight, pregnancy and cigarette smoking significantly influenced the prevalence of symptoms. Medication (most commonly antacids) was used by only 16% of the symptomatic people, and only 5.5% had sought medical advice for symptoms during the past year.
Thus, despite commonness of symptoms suggestive of gastro-oesophageal reflux disease only a minority of the individuals suffering from such symptoms use medication or have medical consultation.
Isolauri J & Laippala P: Prevalence of symptoms suggestive of gastro-oesophageal reflux disease in an adult population. Ann Med, 1995 Feb, 27:1, 67-70.
H. Pylori & heartburn
H. pylori (1)
Cure of Helicobacter pylori infection leads to the disappearance of acid-neutralizing substances. Also, patients with ulcer after cure may gain weight.
Investigated whether cure of the infection increases the risk of reflux esophagitis.
The estimated incidence of reflux esophagitis within 3 years was 25.8% after cure of the infection and 12.9% when the infection was ongoing. Patients who developed reflux esophagitis after the cure had a more severe body gastritis before cure, gained weight more frequently after cure, and were predominantly men.
A considerable proportion of patients with duodenal ulcer treated for H. pylori will develop reflux esophagitis; risk factors are male sex, severity of corpus gastritis, and weight gain.
Labenz J et l., Curing Helicobacter pylori infection in patients with duodenal ulcer may provoke reflux esophagitis. Gastroenterology, 1997 May, 112:5, 1442-7.
H. pylori (2)
Helicobacter pylori is a human pathogen that colonises the gastric mucosa and causes permanent gastric inflammation.
Assessed the symptoms of H pylori infection in an adult unselected population.
People with increased levels of IgG antibodies to H pylori were more likely than uninfected individuals to report heartburn and abdominal pain.
H pylori infection may precede the development of dyspepsia and is associated with a variety of gastrointestinal symptoms in people with no history of peptic ulcer disease.
Rosenstock S et al., Relation between Helicobacter pylori infection and gastrointestinal symptoms and syndromes. Gut, 1997 Aug, 41:2, 169-76.
Healing & heartburn
Esophagitis healing proportions are often incorrectly called the healing rate.
Compared different drug classes by expressing the speed of healing and symptom relief through a new approach.
Mean overall healing proportion irrespective of drug dose or treatment duration (< or =12 weeks) was highest with proton pump inhibitors vs. H2-receptor antagonists, sucralfate, or placebo. PPIs provided faster (nearly twice as fast), more complete heartburn relief.
Chiba N et al., Speed of healing and symptom relief in grade II to IV gastroesophageal reflux disease: a meta-analysis. Gastroenterology, 1997 Jun, 112:6, 1798-810.
Infants & heartburn
Assessed clinical and radiological findings of gastro-oesophageal reflux in adults who were diagnosed as having a hiatal hernia in infancy or early childhood
The consumption of antacids was significantly lower (20% v 46%) in patients who responded well to treatment as children.
Despite the persistence of the hiatal hernia in half of the non-surgically treated patients, few complained of significant symptoms. Effective treatment in childhood was associated with a significant reduction in antacid consumption for heartburn as adults.
Johnston BT et al., Twenty to 40 year follow up of infantile hiatal hernia. Gut, 1995 Jun, 36:6, 809-12.
Mechanisms of heartburn
Gastroesophageal reflux can occur because of low resting pressure, transient relaxation, or normal relaxation of the lower esophageal sphincter. Mechanisms for delayed esophageal clearance include impaired peristalsis, infrequent swallowing, and impaired sphincter relaxation.
Examined esophageal function in patients with gastroesophageal reflux and determined esophageal acid clearance.
Frequency of gastroesophageal reflux is the same during normal and transient sphincter relaxation in heartburn patients. Primary peristalsis is necessary to accomplish acid clearance. Secondary peristalsis is rare and ineffective.
Allen ML et al., Mechanisms of gastroesophageal acid reflux and esophageal acid clearance in heartburn patients. Am J Gastroenterol, 1996 Sep, 91:9, 1739-44.
NSAIDs & heartburn
Upper gastrointestinal tract symptoms are common in the elderly and, despite a paucity of data, nonsteroidal antiinflammatory drugs (NSAIDs) are believed to be important risk factors.
Evaluated the association of NSAIDs with dyspepsia and heartburn in a population-based study.
The annual prevalences of dyspepsia and heartburn were 15.0 and 12.9, respectively. Aspirin was associated with dyspepsia and/or heartburn as were nonaspirin NSAIDs, but smoking and alcohol were not significant risk factors.
Aspirin and nonaspirin NSAIDs are associated with almost a twofold risk of upper gastrointestinal tract symptoms in elderly community subjects.
Talley NJ et al., Nonsteroidal antiinflammatory drugs and dyspepsia in the elderly [see comments]. Dig Dis Sci, 1995 Jun, 40:6, 1345-50.
Obesity & heartburn
Massively obese patients [# 50 with a body mass index (BMI) of 42.5 +/- 5.2 kg/m2 and an actual weight of 125.5 +/- 17 kg] referred for gastroplasty operations were prospectively studied to determine the existence of gastroesophageal reflux disease by means of a standardized questionnaire, 24-hr ambulatory pH-metry, and endoscopy (27 females, mean age 48 years, range 38-57 years).
Heartburn and acid regurgitation was reported by 37% and 28%, respectively, mostly of a mild degree (22% and 20%).
Results suggest that massive overweight is not associated with an increased prevalence of gastroesophageal reflux disease.
Lundell L et al., Does massive obesity promote abnormal gastroesophageal reflux? Dig Dis Sci, 1995 Aug, 40:8, 1632-5.
Osteomalacia & heartburn
A 49-year-old woman suffering from generalized skeletal pain and multiple fractures accompanied by severe hypophosphataemia and low urinary phosphorus excretion is reported.
She had been taking large amounts of antacids containing aluminum hydroxide for many years. A diagnosis of antacid-induced osteomalacia was made.
Clinical improvement was achieved by withdrawal of antacids and phosphorus administration. The literature concerning this unusual condition has been reviewed.
Boutsen Y et al., Antacid-induced osteomalacia. Clin Rheumatol, 1996 Jan, 15:1, 75-80.
Pectin & heartburn
Gastro-oesophageal reflux disease may be treated with a drug forming a floating neutral raft in the stomach.
Examined the pectin-based raft-forming anti-reflux agent Aflurax (Idoflux). First regarding reduction of oesophageal acid exposure, and next as to its efficacy as maintenance treatment in patients with healed oesophagitis.
Maintenance treatment for up to 6 months with two tablets of Aflurax 1200 mg or placebo four times daily.
The median (interquartile range) acid exposure times in the upright position were: 3.1% on Aflurax versus 6.7% on placebo. In the supine position no difference was found (Aflurax 13.7%, placebo 13.2%).
The time to recurrence of heartburn with Aflurax treatment was prolonged significantly; after 6 months the life table estimates were 48% of patients in remission on Aflurax versus 8% on placebo.
Following treatment, erosive oesophagitis was found in 17/34 on Aflurax versus 28/38 on placebo (P < 0.05).
Aflurax significantly delays recurrence of moderate or severe heartburn and erosive oesophagitis, when used as maintenance treatment. The acid exposure was not significantly reduced with pH monitoring.
Havelund T et al., Efficacy of a pectin-based anti-reflux agent on acid reflux and recurrence of symptoms and oesophagitis in gastro-oesophageal reflux disease. Eur J Gastroenterol Hepatol, 1997 May, 9:5, 509-14.
Psychosocial & heartburn
Determined whether individuals who consult a doctor for gastroesophageal reflux disease have psychological characteristics and social support patterns that distinguish them from those who remain within the community.
Heartburn sufferers who remained within the community in no way differed from healthy controls. Patients who sought medical attention were older and their heartburn was more severe than community heartburn sufferers.
Psychological and social factors are associated with individuals with gastroesophageal reflux disease who seek medical help.
Johnston BT et al., Health care seeking by heartburn sufferers is associated with psychosocial factors. Am J Gastroenterol, 1996 Dec, 91:12, 2500-4.
Red wine & heartburn
Assessed the effects of red wine taken with meals on esophageal motility, esophageal exposure to acid, and gastric pH.
Ingestion of moderate amounts of red wine with meals increases postprandial esophageal exposure to gastric acid in healthy persons.
Grande L et al., Effects of red wine on 24-hour esophageal pH and pressures in healthy volunteers. Dig Dis Sci, 1997 Jun, 42:6, 1189-93.
Self-medication for heartburn
After 177 were interviewed, 143 underwent upper gastrointestinal endoscopy. Of those, 106 (74%) experienced symptoms at least once a week. These were relieved by alginate consumption in 97 (68% of) cases. Just nine (6%) patients had been taking H2-receptor antagonists.
Patients who self-medicate for reflux symptoms have a low prevalence of pre-neoplastic and neoplastic pathology. A substantial proportion, however, have histological evidence of oesophagitis and a small number have metaplasia.
Corder AP et al., Heartburn, oesophagitis and Barrett's oesophagus in self-medicating patients in general practice. Br J Clin Pract, 1996 Jul-Aug, 50:5, 245-8.
Stress & heartburn
In 40% of patients presenting to medical clinics with heartburn, no objective evidence of gastro-oesophageal reflux disease can be demonstrated.
Assessed the psycho-social profiles of patients presenting with heartburn in an attempt to discriminate between those with pathological reflux and those with functional disease.
Patients with functional heartburn did not report any increase in daily hassles nor did they have higher levels of anxiety, depression or other psychological characteristics than those with objective reflux disease.
Differences in psychological characteristics and social support structures do not offer an explanation for the heartburn experienced by patients in the absence of objective evidence of reflux disease. Other explanations, including visceral hypersensitivity, should be sought in these patients.
Johnston BT et al., Stress, personality and social support in gastro-oesophageal reflux disease. J Psychosom Res, 1995 Feb, 39:2, 221-6.
Systemic sclerosis & heartburn
Tested the effect of body position on oesophageal acid clearance time in patients with systemic sclerosis.
In healthy subjects the body position did not affect acid clearance time, whereas in patients the oesophagus cleared mainly by gravity. In patients the acid clearance time was significantly longer in the supine than in the seated position. Nine patients did not have a detectable peristaltic wave in the distal oesophagus. In the other six oesophageal peristalsis was still detectable but contractions had reduced amplitude and often had double and triple peaks; also in this subgroup the acid clearance time recorded in the supine position was prolonged.
In systemic sclerosis gravity plays a major role in oesophageal acid clearance time. The finding of delayed acid clearance in a supine patient may suggest initial oesophageal involvement in the disease.
Basilisco G et al., Oesophageal acid clearance in patients with systemic sclerosis: effect of body position. Eur J Gastroenterol Hepatol, 1996 Mar, 8:3, 205-9.
Meal Type & heatburn
Meal Type
Chili, hamburger, and sausage biscuits cause heartburn more than other meals, according to this study in 12 patients over a 24-hour period. Increases in reflux occurred over baseline from hamburger, sausage biscuit and chili meals. The sausage biscuit and chili increased reflux compared to the hamburger. The chili did not differ statistically from the sausage biscuit meal. Even though they had lower fat content, chili and red wine caused more reflux and heartburn than other meals.
Rodriguez, Sheila, Ph.D., et al: Meal Type Affects Heartburn Severity, Digestive Diseases and Sciences, March, 1998;43(3):485-490.
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