A recent study (SJ Spechler et al. NEJM 2019; 381: 1513-23) on first glance appears to support surgery as more effective than medical treatment for refractory heartburn.
Only ~20% of enrolled patients were included in the reported outcomes!
Here’s what happened. Among a cohort of VA patients (n=360, mean age 48 years) who were reportedly refractory to PPI-treatment:
- 78 were excluded during prerandomization
- 42 had relief of their heartburn during a 2-week omeprazole lead-in (20 mg BID)
- 70 did not complete trial procedures
- 23 had non-GERD disorders
- 99 had functional heartburn
This left 78 patients who underwent randomization. All patients in this highly-selected group had undergone endoscopy with biopsy, impedance-pH testing, and esophageal manometry. 18 of 27 (67%) had treatment success with surgery compared to 7 of 25 patients treated with baclofen/PPI and 3 of 26 with control medical treatment (PPI alone).
- Careful evaluation is needed in any patient with refractory heartburn, especially if contemplating surgery. Most will either respond to PPI treatment or have a disorder other than reflux; the authors note that 122 patients (out of 360 patients) did NOT have reflux –99 had functional heartburn.
- Careful instruction in PPI use can be helpful. Omeprazole and similar agents should be taken 30 minutes before meals.
- The authors noted that in addition to reflux, that reflux hypersensitivity can “respond to fundoplication…treatment success was 71% among the 14 with reflux hypersensitivity and 62% among the 13 with abnormal acid reflux.”
Limitations: The VA population is not representative of the general population; this trial had a predominance of white males. Also, it is hard to exclude that some of the ‘success’ of the procedure could relate to a powerful placebo response.
My take: This trial reinforces the notion that reflux surgery is helpful in very few highly-selected patients.
Related blog posts:
A recent randomized, placebo-controlled cross-over study by A Pauweis et al (Am J Gastroenterol 2018; 113: 97-104) indicated that baclofen improved rumination syndrome in adults (mean age 42 years). Thanks to Ben Gold for this reference.
Baclofen (dosed at 10 mg TID) had the following effects:
- reduced rumination episodes from 13 (8-22) to 8 (3-11) (P=0.004)
- increased lower esophageal sphincter (LES) pressure (17.8 vs. 13.1, P=0.0002) and lowered number of transient LES relaxations (4 vs 7, P=0.17)
- overall treatment evaluation was superior after baclofen compared to placebo (P=0.03)
My take: In this study, baclofen improved symptoms of rumination and regurgitation, but not supragastric belching.
“Escape” stairs in Hoover Dam
Treatment options for rumination and for belching are limited. Baclofen improves symptoms and decreases events in both of these disorders (Clin Gastroenterol Hepatol 2012; 10: 379-84).
Rumination is characterized by effortless regurgitation of recently ingested food into the mouth (or beyond). It is easily mistaken for vomiting disorders and motility disturbances. With rumination, patients have retrograde flow of gastric contents into the esophagus through voluntary, though unintentional, abdominal muscle contractions with increased intragastric pressure increases.
Supragastric belching occurs when air is sucked into the esophagus by decreasing the intrathoracic pressure or by contracting pharyngeal muscles.
Baclofen is an agonist of the γ-aminobutyric acid B (GABA) receptor which results in increased lower esophageal sphincter (LES) pressures and reduced swallowing rates. Baclofen has been shown to improve reflux, mainly by reducing transient LES relaxations (TLESRs) but also by increasing basal LES pressures.
In the majority of patients, the mainstay of treatment has been behavioral which use diaphragmatic breathing to compete/extinguish these behaviors. There are a shortage of therapists familiar with this approach. As such, alternative treatments are needed. In this study, high-resolution manometry-impendance recordings were taken from 16 patients (10 women; mean age 43 years; range 18-89 years); eight of the patients had rumination. Only 12 patients were included in the final analysis; four patients refused repeat manometry. Manometry was performed before and after treatment along with recording symptoms. Both symptoms and manometry recordings improved with Baclofen therapy. This was a one-week open-label study. Baclofen was dosed at 10 mg TID. At baseline the total number of “flow events” was 473; after treatment, this was reduced to 282 events. In total, rumination events decreased by 68% during treatment. This improvement correlated with increased LES pressures.
Four of the 12 patients reported mild side effects mainly sleepiness and difficulty concentrating.
- -Clin Gastroenterol & Hep 2007; 5:772. Review. Supragastric belching usually due to aerophagia and is very frequen (up to 20/hr)t. GERD related belching is less infrequent, has sour taste, usually less loud & after meals. Gum chewing, excessive beverage drinks, rapid eating or drinking, smoking or using straw for drinking may increase air in the stomach and lead to burping which can be behavioural problem as well.
- -“Behavioral Treatment of Chronic Belching Due to Aerophagia in a Normal Adult” Behav Modif 2006; 30; 341
- -JPGN 2011; 52: 414. Mgt of severe rumination @ Columbus Ohio. n=5. Definitive dx established with AD manometry with typical r-wave pattern (when regurgitates after a meal)
- -JPGN 2010; 50: 103. Rumination occurring in NL intelligent adolescents. May start with regurgitation and progress to inability to swallow saliva.
- -Clin Gastro & Hep 2006; 4: 1314. Review of management of rumination/case presentation
- -Chitkara et al: Teaching diaphragmatic breathing for rumination syndrome. Am J Gastroenterol. 2006 Nov;101(11):2449-52. Review. Can use behavioral interventions such as deep breathing exercises/ diaphragmatic breathing to break the spasms..
- -Gastroenterology 2006; 130: 1527-28. Review and criteria of rumination.
- -Pediatrics 2003; 111: 158-62. Review of rumination dx, Rx, & prognosis.
- -Clin Persp in Gastro 2000; 3 (5): 277.
Additional Baclofen references:
- -J Pediatr 2006; 149: 436, 468. Baclofen reduces GER. 0.5mg/kg/day
- -JPGN 2004; 38: 317. Effectiveness of baclofen in neurologically-impaired children w GER. (0.7/kg/day), n=8.
- -Gastroenterology 2000; 118: 7-13. Use of baclofen to reduce TLESR.
- -Aliment Pharm Ther 2003; 17: 243-51. Baclofen reduced GER (acid & nonacid). side effects -N, V, dizzy. dose: in adults, start at 5mg tid, increase c 5mg increments every 4th day to 10-20mg tid.