PO Katz et al The American Journal of Gastroenterology: January 2022 – Volume 117 – Issue 1 – p 27-56doi: 10.14309/ajg.0000000000001538. Open Access: ACG Clinical Guideline for the Diagnosis and Management of Gastroesophageal Reflux Disease
Related blog post: 2018 Pediatric Gastroesophageal Reflux Clinical Practice Guidelines
This is a useful review -with helpful diagrams: Full text Ten Things Every Gastroenterologist Should Know About Antireflux Surgery (S Park et al. Clin Gastroenterol Hepatol 2020; 18: 1923-1929)
A couple excerpts:
Selecting Patients for Surgery: Current guidelines fall short in determining appropriate patients who would benefit most from surgery. For instance, the recommendation that a desire to discontinue PPI therapy is a suitable indication for antireflux surgery fails to recognize that 62% of patients end up back on PPIs within 9 years. Furthermore, indicating that those patients who failed medical management would benefit from surgery neglects the fact that the patients who respond best to antireflux surgery are those who have responded well to PPI therapy in the first place
Complications: Late postoperative complaints are more common and often are referred back to the referring gastroenterologist for diagnosis and management. These include late-onset dysphagia (3%–24%), recurrent heartburn (up to 62%), gas-bloat syndrome (up to 85%), and diarrhea (18%–33%). Anatomic failure of the fundoplication (Figure Below) can present a unique challenge to the clinician because the symptoms and patient presentation (postoperative dysphagia, regurgitation, and heartburn) can be clinically indistinct from the issues seen commonly after this surgery even in the best of circumstances. Therefore, the gastroenterologist should assess symptoms carefully in a stepwise approach with upper endoscopy, barium swallow, esophageal manometry, and/or ambulatory pH monitoring when appropriate and plan any interventions based on objective findings from focused testing.
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In adults with gastroesophageal reflux, there is more data that magnetic sphincter augmentation (MSA) is a good option for many. R Bell et al. Clin Gastroenterol Hepatol 2020; 18: 1736-1743. Full Text: Magnetic Sphincter Augmentation Superior to Proton Pump Inhibitors for Regurgitation in a 1-Year Randomized Trial)
Methods: Patients with moderate to severe regurgitation (assessed by the foregut symptom questionnaire) despite once-daily PPI therapy (n = 152) were randomly assigned to groups given twice-daily PPIs (n = 102) or laparoscopic MSA (n = 50) at 20 sites.
Key findings:
Discussion points from authors:
In the associated editorial, JE Richter (Clin Gastroenterol Hepatol 2020; 18: 1685-1687 Full text: Laparoscopic Magnetic Sphincter Augmentation: Potential Applications and Safety Are Becoming More Clear—But the Story Is Not Over) notes that “erosion and migration of the MSA device have been a rare event thus far. In a total of nearly 10,000 device placements, there were 29 reported cases of erosions…Smaller devices were associated with higher rates of erosions. The 12-bead device was responsible for 18 of 29 erosions (62%) and is no longer available for implantation…To an admitted skeptic about new antireflux treatments, the available data about the symptomatic and
physiological effectiveness, durability, and safety of MSA are very impressive. I believe this procedure now deserves to be routinely done as an alternative surgical procedure to traditional fundoplication for patients with mild-moderate GERD….patients with severe GERD and structural sphincter dysfunction still need the traditional fundoplication”
My take: This study and others shows that MSA (aka Linx) is an effective treatment option for many adult patients with medically-refractory regurgitative reflux.
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It is surprising to me that almost half of the U.S. thnk that we have handled the pandemic well
In the June issue of Gastroenterology (158: 2015-16), a tribute to George Sachs (1935-2019) recognizes his work in the field of gastroenterology and his development of proton pump inhibitors (PPIs).
Much more work remains as ~30% of patients with gastroesophageal reflux remain symptomatic despite PPI therapy. In the same issue, IW-3718, a bile acid sequestrant colsevelam with a gastric-retentive formulation was studied in 280 patients (MF Vaez et al. Gastroenterol 2020; 158: 2017-19).
Methods: The authors performed a multicenter, double-blind, placebo-controlled 8-weel treatment trial (2016-17); patients received the study drug (500, 1000, 1500 mg) or placebo twice daily. The authors enrolled symptomatic patients (≥4 times per week) with erosive esophagitis or pathologic reflux based on Bravo study (pH<4 for ≥4.2% during at least one 24-hour period). They continued PPI therapy which they had been receiving for a minimum of 8 weeks prior to starting study medication.
Key findings:
Limitations: lack of a centralized review for endoscopy images, high placebo response rate, once daily use of PPI in study, and problems with overlap of functional symptoms
My take: This study shows why a placebo control is needed in reflux studies. While IW-3718 at higher doses was effective, its response appears much less notable when compared with placebo-recipients.
A recent study (SD Delshad, CV Almario et al. Gastroenterol 2020; 158: 1250-61) used survey data from an APP, MyGiHealth, to assess prevalence of reflux symptoms and symptoms that had not responded to proton pump inhibitor treatment.
Key findings:
Limitations:
My take: There are a lot of folks with reflux symptoms and many have ongoing symptoms despite treatment; hence, lots of opportunity to help (and job security)
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Also from NY Times: Coronavirus Ravaged a Choir. But Isolation Helped Contain It.
“One sick singer attended choir practice, infecting 52 others, two of whom died. A study released by the C.D.C. shows that self-isolation and tracing efforts helped contain the outbreak.” Only 8 of the 61 choir members did not get sick.
Graphical Abstract
A useful review (DA Katzka et al. Clin Gastroenterol Hepatol 2020; 18: 767-76) discusses the phenotypes of gastroesophageal reflux and related disorders. The authors note that consensus initiatives (Montreal, Rome, and Lyon) have looked at these disorders from different perspectives and their goal was to merge their perspectives.
Table 1 lists the major phenotypes:
Figure 1 provides a model for the pathogenesis of GERD. Figure 2 describes the relationship between reflux phenotypes and PPI responsiveness:
In those with typical reflux symptoms:
In those with atypical reflux symptoms:
Other useful points:
My take (borrowed in part from authors): PPIs work well for esophagitis and documented reflux; “the broad spectrum of syndromes [are] much less amenable to PPI therapy in any dose.”
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Curbside Humor
A recent retrospective study (A Rengarajan et al. Clin Gastroenterol Hepatol 2020; 18: 589-95), with a cohort of 371 patients (mean age 54 years) shows how impedance testing may help identify patients who are likely to respond to reflux management when pH probe testing is equivocal. The cohort included adults with persistent reflux symptoms. Response to antireflux therapy was defined as >50% improvement in esophageal symptoms.
Key points:
Response to Treatment:
My take: The big takeaway is that all of our tests for pathologic reflux are highly flawed; impedance may (to a small degree) help stratify patients with equivocal evaluation based on AET. Normal tests do not exclude response treatment (especially surgery).
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Island Ford, Sandy Springs
Briefly noted: DR Duncan et al. J Pediatr 2019; 211: 112-9.
In this retrospective cohort study of infants with brief resolved unexplained events (BRUEs) at Boston Children’s Hospital, the authors examined guideline implementation among 359 subjects in the year before and the year after AAP guidelines.
Key findings:
My take: The pendulum is (slowly) starting to swing back from blaming everything (including BRUEs) on reflux but this change is not evident in this study.
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A recent study (CR Collins et al. J Pediatr 2019; 206; 240-7) showed that symptoms alone are not able to predict the degree/presence of reflux in infants.
Methods: The authors recruited ‘symptomatic’ infants with median 41 weeks postmenstrual age (median 29 weeks at birth) and employed a combination of 24-hour pH-impedance to determine acid reflux index (ARI) and subsequently used provocative esophageal infusions (with air, water then apple juice) to assess manometry and symptoms. In total, they analyzed 2635 separate esophageal stimula in 74 infants.
The authors considered ARI <3% as normal, 3-7% as indeterminate ARI, and >7% as abnormal ARI.
Symptoms that they recorded included arching, irritability, cough, gag, sneeze, gasp, bradycardia, desaturation, throat clearing, startle, grimace, grunting, mouthing, and yawning.
Key findings:
My take: All infants with and without reflux have a lot of “symptoms.” Nonacid reflux is much more likely to provoke symptoms in this population than acid reflux reinforcing the idea that acid suppression is likely ineffective and potentially harmful. “The findings of this study challenge the rationale for instituting anti-GERD therapies in neonates based on either symptoms alone or the existing acid-reflux indices or pH-impedance metrics.”
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Link to article cited below from The Onion: Dog Feels Like He Always Has To Be ‘On’ Around Family Thanks to Jennifer for this reference.
Disclaimer: These blog posts are for educational purposes only. Specific dosing of medications/diets (along with potential adverse effects) should be confirmed by prescribing physician/nutritionist. This content is not a substitute for medical advice, diagnosis or treatment provided by a qualified healthcare provider. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a condition.
A recent retrospective study (Mitre E, et al. JAMA Pediatr. 2018;doi:10.1001/jamapediatrics.2018.0315) suggests that acid blockers, both histamine receptor antagonists and proton pump inhibitors increase the risk of developing allergic disease. Since this is a retrospective study, this association with allergic diseases has NOT been proven to have a causal relationship; thus, an alternative explanation would be that infants who are likely to develop allergic diseases could be prescribed these agents more frequently due to symptoms attributed to reflux.
Here is an excerpt from a summary of this study (from Healio): Acid-suppressor, antibiotic use in infancy tied to later allergic disease
Of the 792,130 children included in the study (49.9% female), 7.6% were prescribed a histamine-2 receptor antagonist (H2RA) and 1.7% were prescribed a proton pump inhibitor (PPI) within the first 6 months of life. Antibiotics also were prescribed for 16.6% of infants included in the study during this time. Mitre and colleagues noted that data continued to be collected on these infants for a median of 4.6 years…
When children were prescribed an H2RA, the researchers noted adjusted HRs of 2.18 (95% CI, 2.04-2.33) for food allergy, 1.70 (95% CI, 1.60-1.80) for medication allergy, 1.51 (95% CI, 1.38-1.66) for anaphylaxis, 1.50 (95% CI, 1.46-1.54) for allergic rhinitis and 1.25 (95% CI, 1.21-1.29) for asthma.
Infants who were prescribed PPIs had comparable aHRs, which the researchers observed at 2.59 (95% CI, 2.25-3.00) for food allergy, 1.84 (95% CI, 1.56-2.17) for medication allergy, 1.45 (95% CI, 1.22-1.73) for anaphylaxis and 1.44 (95% CI, 1.36-1.52) for asthma.
Mitre and colleagues also calculated the aHRs related to later allergic disease in children who were prescribed antibiotics within the first 6 months of life. They observed these rates at 2.09 (95% CI, 2.05-2.13) for asthma, 1.75 (95% CI, 1.72-1.78) for allergic rhinitis, 1.51 (95% CI, 1.38-1.66) for anaphylaxis and 1.42 (95% CI, 1.34-1.50) for allergic conjunctivitis.
My take: This study is another reminder that these agents may be more detrimental than beneficial in the vast majority of infants.
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gutsandgrowth 