The Efficacy of Peroral Endoscopic Myotomy vs Pneumatic Dilation as Treatment for Patients With Achalasia Suffering From Persistent or Recurrent Symptoms After Laparoscopic Heller Myotomy: A Randomized Clinical Trial.

BACKGROUND & AIMS: For patients with achalasia experiencing persistent or recurrent symptoms after laparoscopic Heller myotomy (LHM), pneumatic dilation (PD) is the most frequently used treatment. Per-oral endoscopic myotomy (POEM) is increasingly being investigated as rescue therapy. This study aimed to determine the efficacy of POEM vs PD for patients with persistent or recurrent symptoms after LHM. METHODS: This randomized multicenter controlled trial included patients after LHM with an Eckardt score >3 and substantial stasis (≥2 cm) on timed barium esophagogram and randomized to POEM or PD. The primary outcome was treatment success, defined as an Eckardt score of ≤3 and without unscheduled re-treatment. Secondary outcomes included the presence of reflux esophagitis, high-resolution manometry, and timed barium esophagogram findings. Follow-up duration was 1 year after initial treatment. RESULTS: Ninety patients were included. POEM had a higher success rate (28 of 45 patients [62.2%]) than PD (12 of 45 patients [26.7%]; absolute difference, 35.6%; 95% CI, 16.4%-54.7%; P = .001; odds ratio, 0.22; 95% CI, 0.09-0.54; relative risk for success, 2.33; 95% CI, 1.37-3.99). Reflux esophagitis was not significantly different between POEM (12 of 35 [34.3%]) and PD (6 of 40 [15%]). Basal lower esophageal sphincter pressure and integrated relaxation pressure (IRP-4) were significantly lower in the POEM group (P = .034; P = .002). Barium column height after 2 and 5 minutes was significantly less in patients treated with POEM (P = .005; P = .015). CONCLUSIONS: Among patients with achalasia experiencing persistent or recurrent symptoms after LHM, POEM resulted in a significantly higher success rate than PD, with a numerically higher incidence of grade A-B reflux esophagitis. NETHERLANDS TRIAL REGISTRY: NL4361 (NTR4501), https://trialsearch.who.int/Trial2.aspx?TrialID = NTR4501.

Survival after antireflux surgery versus medication in patients with reflux oesophagitis or Barrett's oesophagus: multinational cohort study.

BACKGROUND: The aim was to examine the hypothesis that antireflux surgery with fundoplication improves long-term survival compared with antireflux medication in patients with reflux oesophagitis or Barrett's oesophagus. METHOD: Individuals aged between 18 and 70 years with reflux oesophagitis or Barrett's oesophagus (intestinal metaplasia) documented from in-hospital and specialized outpatient care were selected from national patient registries in Denmark, Finland, Iceland, and Sweden from 1980 to 2014. The study investigated all-cause mortality and disease-specific mortality, comparing patients who had undergone open or laparoscopic antireflux surgery with fundoplication versus those using antireflux medication. Multivariable Cox regression analysis was used to estimate hazard ratios (HRs) with 95 per cent confidence intervals for all-cause mortality and disease-specific mortality, adjusted for sex, age, calendar period, country, and co-morbidity. RESULTS: Some 240 226 patients with reflux oesophagitis or Barrett's oesophagus were included, of whom 33 904 (14.1 per cent) underwent antireflux surgery. The risk of all-cause mortality was lower after antireflux surgery than with use of medication (HR 0.61, 95 per cent c.i. 0.58 to 0.63), and lower after laparoscopic (HR 0.56, 0.52 to 0.60) than open (HR 0.80, 0.70 to 0.91) surgery. After antireflux surgery, mortality was decreased from cardiovascular disease (HR 0.58, 0.55 to 0.61), respiratory disease (HR 0.62, 0.57 to 0.66), laryngeal or pharyngeal cancer (HR 0.35, 0.19 to 0.65), and lung cancer (HR 0.67, 0.58 to 0.80), but not from oesophageal cancer (HR 1.05, 0.87 to 1.28), compared with medication, The decreased mortality rates generally remained over time. CONCLUSION: In patients with reflux oesophagitis or Barrett's oesophagus, antireflux surgery is associated with lower mortality from all causes, cardiovascular disease, respiratory disease, laryngeal or pharyngeal cancer, and lung cancer, but not from oesophageal cancer, compared with antireflux medication.

Gender-Specific Risk Factors for Reflux Esophagitis in a Predominantly Hispanic Population of a Large Safety-Net Hospital.

BACKGROUND: Defining factors associated with severe reflux esophagitis allows for identification of subgroups most at risk for complications of strictures and esophageal malignancy. We hypothesized there might be unique clinical features in patients with reflux esophagitis in a predominantly Hispanic population of a large, safety-net hospital. AIM: Define clinical and endoscopic features of reflux esophagitis in a predominantly Hispanic population of a large, safety-net hospital. METHODS: This is retrospective comparative study of outpatients and hospitalized patients identified with mild (Los Angeles Grade A/B) and severe (Los Angeles Grade C/D) esophagitis through an endoscopy database review. The electronic medical record was reviewed for demographic and clinical data. RESULTS: Reflux esophagitis was identified in 382/5925 individuals: 56.5% males and 79.8% Hispanic. Multivariable logistic regression model adjusted for age, gender, race, body mass index (BMI), tobacco and alcohol use, and hospitalization status with severity as the outcome showed an interaction between gender and BMI (p ≤ 0.01). Stratification by gender showed that obese females had decreased odds of severe esophagitis compared to normal BMI females (OR = 0.18, 95% CI = 0.07-0.47; p < 0.01). In males, the odds of esophagitis were higher in inpatient status (OR = 2.84, 95% CI = 1.52 - 5.28; p < 0.01) and as age increased (OR = 1.37, 95% CI = 1.03 - 1.83; p = 0.03). CONCLUSIONS: We identify gender-specific associations with severe esophagitis in a predominantly Hispanic cohort. In females, obese BMI appears to be protective against severe esophagitis compared to normal BMI, while in men inpatient status and increasing age were associated with increased odds of severe esophagitis.

[The frequency and clinical aspects of extraesophageal syndromes in elderly patients with gastroesophageal reflux disease].

AIM: To investigate the frequency of extraesophageal syndromes in elderly patients with gastroesophageal reflux disease (GERD). MATERIALS AND METHODS: This cross-sectional study was conducted to compare the clinical manifestations of GERD in 1100 patients aged 60 to 75 years and in 453 patients aged 36 to 60 years. A control group consisted of 154 elderly patients without GERD and 178 mature-aged patients without this condition. GERD was diagnosed via analysis of its symptoms, esophagogastroduodenoscopy, and 24-hour pH monitoring on the basis of the Montreal consensus guidelines. Extraesophageal syndromes were detected actively using the current methods accepted to treat lung, heart, and ENT diseases and a simultaneous gastroesophageal examination. RESULTS: Chronic cough, asthma, chronic laryngitis, cardialgias and cardiac arrhythmias were much more common in elderly patients with GERD than in those without this condition and prevalent in patients with erosive esophagitis and Barrett's esophagus as compared with those with non-erosive reflux disease. The mature-aged patients were recorded to have similar but less pronounced trends. The authors proposed an algorithm for the management of patients with extraesophageal manifestations of GERD, the important aspect of which was two-month acid-suppressive therapy used as both diagnostic testing and empirical treatment for this pathology. CONCLUSION: The extraesophageal manifestations of GERD in elderly patients are a serious clinical problem calling for considerable attention.

[Clinical, endoscopic and morphological manifestations of oesophageal lesion in systemic scleroderma].

UNLABELLED: Oesophageal lesion is the commonest visceral manifestation of systemic scleroderma (SSD) affecting the quality of life and fraught with serious complications. The aim of this study was to evaluate clinical, endoscopic andmorphological manifestations of oesophageal lesion in systemic scleroderma and its relationships with other clinical symptoms and pharmacotherapy of the disease. MATERIALS AND METHODS: 479 patients with SSD (93.7% women, 6.3% men, mean age 48.7 +/- 19.2 yr). All of them underwent EGDS in 2005-2010. 123 patients were examined for the detection of Barrett's oesophagus (BO), total screening regardless of complaints was conducted in 2010. Control group included 1018 age and sex-matched patients with RA who underwent EGDS in 2008-2009. RESULTS: Oesophageal lesions occurred much more frequently in SSD than in RA. Oesophageal symptoms were documented in 70.0 and 29.9% cases, non-erosive oesopahgitis in 28.8 and 1.5%, erosive esophagitis in 22.5 and 2.2% ulcers in 0.8 and 0% (p < 0.001). BO manifested as intestinal metaplasia (histological study of mucosal biopsy) was found in 30 SSD patients (4.2%). Screening revealed BO in 8.9% of the patients. The development of erosive oesophagitis was unrelated to the age of the patients, duration of the disease and its form (localized or diffusive), lung pathology or Sjogren's syndrome. Cytotoxic medicines significantly increased the frequency of erosive oesophagitis, it tended to increase under effect of NSAID and low doses of aspirin. Long-term intake of PPI did not reduce the risk of oesophagitis and BO. CONCLUSION: Half of the patients with SSD have oesophagitis. Over 20% of them suffer its complications (erosion and ulcers) and 9% have BO. All such patients need endoscopic study ofoesophagus regardless of clinical symptoms.

The path(ology) from reflux oesophagitis to Barrett oesophagus to oesophageal adenocarcinoma.

This review seeks to summarise the steps in the path from reflux oesophagitis to Barrett oesophagus to oesophageal adenocarcinoma. The epidemiology, clinical presentation, definitions, pathological features, diagnostic pitfalls, and emerging concepts are reviewed for each entity. The histological features of reflux oesophagitis can be variable and are not specific. Cases of reflux oesophagitis with numerous eosinophils are difficult to distinguish from eosinophilic oesophagitis and other oesophagitides with eosinophils (Crohn's disease, medication effect, and connective tissue disorders). In reflux oesophagitis, the findings are often most pronounced in the distal oesophagus, the eosinophils are randomly distributed throughout the epithelium, and eosinophilic abscesses and degranulated eosinophils are rare. For reflux oesophagitis with prominent lymphocytes, clinical history and ancillary clinical studies are paramount to distinguish reflux oesophagitis from other causes of lymphocytic oesophagitis pattern. For Barrett oesophagus, the definition remains a hotly debated topic for which the requirement for intestinal metaplasia to make the diagnosis is not applied unanimously across the globe. Assessing for dysplasia is a challenging aspect of the histological interpretation that guides clinical management. We describe the histological features that we find useful in making this evaluation. Oesophageal adenocarcinoma has been steadily increasing in incidence and has a poor prognosis. The extent of invasion can be overdiagnosed due to a duplicated muscularis mucosae. We also describe the technical factors that can lead to challenges in distinguishing the mucosal and deep margins of endoscopic resections. Lastly, we give an overview of targeted therapies with emerging importance and the ancillary tests that can identify the cases best suited for each therapy.

[Reflux esophagitis (esophageal hiatus hernia)].

Recently, the guidelines for the treatment of gastroesophageal reflux disease (GERD) by the Japanese Society of Gastroenterology. There are many statements including recommended grade (from A to D) and evidence level (from I to VI) for the epidemiology, pathogenesis, diagnosis, medical treatments, surgical treatment of GERD, reflux esophagitis after gastrectomy, and non-typical symptoms of GERD. In this manuscript, we showed the latest date and current status of GERD in Japan used this guidelines. In summary, the prevalence of GERD has been increasing since the end of 1990s, the 1st choice of medical treatment is proton pump inhibitors, endoscopic treatments for GERD are not available in Japan, laparoscopic Toupet fundoplication is superior to laparoscopic Nissen fundoplication as postoperative dysphagia with similar reflux control, and complications of surgical treatment are pneumothorax, splenic injury, aortic injury, gastric ulcer, sever dysphagia, gastric perforation etc., but complication rate is low.

[Diagnostic and treatment of gastroesophageal reflux disease].

We propose a diagnostic algorithm based on the evaluation of GERD symptoms, the test results with a single dose of alginate with heartburn and EGD--esophagogastroduodenoscopy data. The diagnosis of GERD with reflux esophagitis based on the endoscopic detection of characteristic changes of esophagus. Diagnostic criteria endoscopically negative forms of GERD are the presence of symptoms of concern to the patient, the absence of damage to the esophagus during EGD and rapid relief of heartburn, a single dose of alginate (alginate positive test). Drug of choice for reflux esophagitis is an PPI. Specify the role of Helicobacter pylori diagnosis, indications for eradication in patients with GERD.

Prevalence of Barrett's esophagus remains low in the Korean population: nationwide cross-sectional prospective multicenter study.

PURPOSE: In contrast to the Western population, the prevalence of Barrett's esophagus (BE) is rare in the Korean population. However, the recent increase in prevalence of gastroesophageal reflux disease (GERD) may affect the prevalence of BE. The aim of this study was to survey the prevalence of BE and evaluate its risk factors. METHODS: Patients between 18 and 75 years of age who visited 11 Korean tertiary referral centers between April and July 2006 for routine upper endoscopic examination were surveyed using a symptom questionnaire. Biopsies were performed on the columnar lined epithelium (CLE) of the distal esophagus, and diagnosis was confirmed with detection of specialized intestinal metaplasia. RESULTS: The study comprised 2,048 patients (mean age 51.4 years, 965 males). The frequency of heartburn or acid regurgitation was 8.7% and 13.1%, respectively. Reflux esophagitis was diagnosed in 10.1% of patients (207 patients); however, most patients had mild reflux. CLE was found in 82 patients; however, only one patient had long-segment CLE. The prevalence of BE was 1% (21 patients). The risk factors for BE were age (P = 0.006), presence of heartburn [odds ratio (OR) 4.33, 95% confidence interval (CI) 1.66-11.34, P = 0.007], acid regurgitation (OR 3.37, 95% CI 1.35-8.42, P = 0.01), sliding hernia (OR 6.21, 95% CI 1.78-21.72, P = 0.001), and reflux esophagitis (OR 10.28, 95% CI 4.31-24.50, P < 0.0001) on univariate analysis. On multivariate analysis, presence of typical reflux symptoms (P = 0.02) and reflux esophagitis (P < 0.001) were significant. CONCLUSIONS: Prevalence of Barrett's esophagus remains low in Koreans; however, risk of developing BE has increased in patients with GERD symptoms and reflux esophagitis.

Time trends of endoscopic and pathological diagnoses related to gastroesophageal reflux disease in a Chinese population: eight years single institution experience.

The discrepancy between Eastern and Western countries exists regarding the time trends of Barrett's esophagus (BE)/adenocarcinoma. We aimed to elucidate this issue through a retrospective review of the endoscopic and pathological diagnoses of gastroesophageal reflux disease (GERD) over time in a Chinese population. All records were analyzed from 2000 to 2007. Records included demographic data, clinical indication for endoscopy, and endoscopic findings. The total number of endoscopic procedures increased over time. The indications for referral endoscopy secondary to GERD increased from 366 cases (4.9%) in the beginning of the study to 1439 cases (14.1%) at the end. Concomitant GERD symptoms did not significantly change (range, 13-15.1%) in screening endoscopic studies. Endoscopic detection of erosive esophagitis increased in referral populations from 1546 (20.7%) to 5207 cases (51%) and by screening endoscopy from 791 (14.5%) to 1983 cases (23.5%). The prevalence of nonerosive reflux disease and BE did not change over time. BE-associated dysplasia and adenocarcinoma were rare. The detection of Los Angeles class A disease increased with time in referral endoscopy cases with a focus on erosive esophagitis composition. The endoscopic demand for GERD investigation and the GERD endoscopic diagnosis increased in our population. The results were related to a higher prevalence of low-grade erosive disease diagnosed. The incidence of BE-associated dysplasia and adenocarcinoma has been the same and the increased screening did not detect more cancers.

[Analysis on acupoint selection rules for reflux esophagitis].

The data mining technology was used to explore the acupoint selection rules for reflux esophagitis (RE), so as to provide references of clinical acupuncture for RE. The clinical literature of acupuncture for RE published before June 2019 was searched in Chinese journal full-text database (CNKI), SinoMed, Wanfang and VIP databases. The literature was selected according to the inclusion and exclusion criteria and acupoint prescriptions were extracted. The software of IBM SPSS Statistics 23.0 and Clementine 12.0 were used for descriptive analysis and association analysis. A total of 46 articles were selected and 60 acupoint prescriptions were extracted. The descriptive analysis indicated that the top five acupoints used for RE were Zhongwan (CV 12), Zusanli (ST 36), Weishu (BL 21), Neiguan (PC 6) and Gongsun (SP 4). The conception vessel, bladder meridian and stomach meridian were the most commonly selected meridians. In terms of specific acupoints, the crossing points, the front-mu points and five-shu points were mainly selected, and the acupoints were mainly distributed in limbs and chest-abdomen. The core acupoint combination for RE was "Zhongwan (CV 12) and Zusanli (ST 36)" and the core prescription was "Zhongwan (CV 12), Zusanli (ST 36), Weishu (BL 21) and Neiguan (PC 6)".

The impact of lifestyle modification on the health-related quality of life of patients with reflux esophagitis receiving treatment with a proton pump inhibitor.

OBJECTIVES: Although lifestyle modification involving diet, exercise, cessation of smoking, etc. is generally advised for patients with reflux esophagitis (RE), few data that show its clinical benefits are available. We analyzed whether lifestyle modification improves health-related quality of life (HRQOL) in Japanese patients with RE receiving the proton pump inhibitor (PPI) lansoprazole as a post hoc analysis of an observational study that investigated the effect of lansoprazole on HRQOL. METHODS: Patients with RE received lansoprazole for 8 weeks. HRQOL was assessed using the 8-Item Short-Form Health Survey (SF-8) and RE-specific HRQOL questionnaires at baseline and after 4 and 8 weeks of treatment. Physical and mental component summaries (PCS, MCS) and RE-specific summary (RES) scores were calculated. RESULTS: Of the 8,757 patients analyzed, 40.8% were advised regarding new lifestyle at the start of lansoprazole treatment (Group A), 33.3% were advised to continue the lifestyle as advised previously (Group B), and 25.9% did not receive any advice (Group C). The change in PCS from baseline at week 8 for Group A was 5.7 +/- 8.1, and this was significantly greater (P < 0.001) than the increases achieved in Groups B (4.3 +/- 7.5) and C (4.0 +/- 7.6). The changes in MCS and RES were also significantly greater in Group A than in the other groups. The changes in HRQOL scores from baseline were significantly greater in Group A than in the other groups, irrespective of baseline patient characteristics. CONCLUSIONS: Lifestyle modification may be clinically beneficial in terms of improving HRQOL in Japanese patients with RE who are receiving treatment with a PPI.

Avoiding pitfalls: what an endoscopist should know in liver transplantation--part II.

Over the last decade the number of patients undergoing transplantation has increased. At the same time, effective peri- and postoperative care and better surgical techniques have resulted in greater numbers of recipients achieving long-term survival. Identification and effective management in the form of adequate treatment is essential, since any delay in diagnosis or treatment may result in graft loss or serious threat to patient's life. Various aspects of endoscopic findings that can be commonly encountered among liver transplant recipients are discussed herein. Topics include: persistent and/or recurrent esophageal varices, reflux, Candida or cytomegalovirus (CMV) esophagitis, esophageal neoplasms, posttransplant peptic ulcer, biliary complications, posttransplant lymphoproliferative disorder (PTLD), Kaposi's sarcoma, CMV colitis and inflammatory bowel disease, colonic neoplasms, Clostridium difficile infection, and graft versus host disease (GVHD).

[The outcomes of treatment of gastroesophageal reflux disease with laparoscopic "floppy" fundoplication]. / Ocena wyników leczenia choroby z zarzucania zoladkowo-przelykowego laparoskopowa metoda pelnej luznej fundoplikacji.

UNLABELLED: Gastroesophageal reflux disease (GERD) has been a serious health and social problem. Population based survey revealed that around 40 per cent of the whole population reported monthly GERD related symptoms. When not treated properly GERD can lead to severe complications such as Barrett's oesophagus (BE) and adenocarcinoma as a consequence. Various methods can be useful in diagnosis of GERD but only gastroscopy is a widespread investigation that enables to establish the diagnosis of reflux disease. The symptoms of reflux disease can be effectively treated by drugs, surgical procedures remain the way of curing the cause of gastroesophageal reflux. Nowadays the laparoscopic fundoplication is a standard in operative treatment of the ailment. AIM OF STUDY: was to evaluate of GERD treatment with laparoscopic "floppy" Nissen fundoplication (LFN). MATERIAL AND METHODS: A group of 41 patients who underwent LNF were recruited for the study. All qualified patients underwent pre and post-surgical upper GI endoscopy and were requested to answer the questions in a GERD-related quality of life questionnaire. The main group of patients was divided into two subgroups--those with concomitant hiatal hernia and those without hernia. The outcomes of treatment were then compared between the subgroups. RESULTS: After the procedure the endoscopic improvement of reflux oesophagitis and better symptoms self-assessment were found. CONCLUSIONS: Laparoscopic "floppy" Nissen fundoplication is an effective method of treatment of erosive oesophagitis and its symptoms.

[Peptic stenosing esophagitis].

The authors have performed examination and treatment of 55 patients with peptic stricture of the esophagus. The algorithm of examination (X-ray method, endoscopic method, express pH-metry of the upper part of the gastrointestinal tract, USI of the abdominal cavity organs) allowed characterization of the stricture, detection of the disease which resulted in its development. The treatment included endoscopic methods (bougienage, balloon dilatation) for restoration of patency of the esophagus, pharmacotherapy directed to suppression of gastric secretion and improving the motor function of the gastrointestinal tract. Frequent relapses of peptic strictures, suspected neoplasias in the patient's esophagus should be treated surgically.

Beneficial effect of probiotics supplements in reflux esophagitis treated with esomeprazole: A randomized controlled trial.

BACKGROUND: Reflux esophagitis (RE) is a common digestive disorder, and its frequent recurrences cause significant physical pain and are financially burdensome to patients. However, studies on the natural history of treated RE are few. Although proton pump inhibitors (PPIs) as the first-line treatment provide notable symptomatic relief, disordered gut microbiota has been observed among PPI users. Probiotics are commonly administered to patients to regulate the disordered intestinal flora. AIM: To evaluate the therapeutic effects in RE patients treated with a combination of esomeprazole and probiotics [Bacillus subtilis (B. subtilis) and Enterococcus faecium (E. faecium)]. METHODS: One hundred and thirty-four RE patients were randomized into two groups of 67 subjects each. The probiotics group was administered with esomeprazole 20 mg b.i.d. and live combined B. subtilis and E. faecium enteric-coated capsules 500 mg t.i.d. for eight weeks; the placebo group was administered with esomeprazole 20 mg b.i.d. and placebo for eight weeks. Subsequently, 12-wk follow-up was carried out on patients who achieved both endoscopic and clinical cure. Endoscopy, reflux diagnostic questionnaire (RDQ), gastrointestinal symptom rating scale (GSRS), and lactulose hydrogen breath test were performed to evaluate the therapeutic effects. A difference of P < 0.05 was considered statistically significant. RESULTS: Sixty-six patients in the probiotics group and 64 patients in the placebo group completed the 8-wk treatment. The healing rate and RDQ score had no significant difference between the two groups (P > 0.05). However, the GSRS diarrhea syndrome score was decreased significantly in the probiotics group (P = 0.002), and the small intestinal bacterial overgrowth negative rate in the probiotics group was significantly higher than that in the placebo group (P = 0.002). Of 114 endoscopically and clinically cured patients, 96 completed the follow-up. The log-rank test showed that the time to relapse was shorter in the placebo group than in the probiotics group (P = 0.041). Furthermore, the therapy had a significant influence on relapse time, and the risk of relapse in the probiotics group was lower than that in the placebo group at any time point during the 12-wk follow-up (hazard ratio = 0.52, P = 0.033). CONCLUSION: Esomeprazole combined with probiotics (B. subtilis and E. faecium) have a beneficial effect on RE treatment and patient management.

[Acid related diseases progress in 2007]. / Maladies peptiques.

The treatment of reflux disease did not changed. PPI treatment remains the first line treatment and surgery a second line treatment. The effect of surgery in reflux disease reduces and, after ten years, a part of the operated patients needs PPI again. The triple therapy is the treatment of choice of Helicobacter pylori infection. Patients with persistent Helicobacter pylori infection, after a first treatment, should be treated with a sequential treatment. PPI are effective in the prevention of gastroduodenal lesions and in the treatment of dyspeptic symptoms during NSAID treatment. IPP should be given to all patients presenting dyspeptic symptoms under NSAID or COX-2 administration.

Cytomegalovirus ulcerative oesophagitis in a young healthy immunocompetent patient.

Cytomegalovirus (CMV) gastrointestinal disease usually arises in patients with immunodeficiency or immunosuppression, being rare in immunocompetent hosts. Although increasing in incidence, few cases of CMV gastrointestinal disease have been described among young healthy patients. Currently, there is uncertainty in approaching these patients, including the need for antiviral therapy that remains to be established. This case report describes a CMV ulcerative oesophagitis in a young healthy immunocompetent patient with good evolution with no need for antiviral therapy, the youngest case being reported in the literature until now.

Current and future perspectives in the management of gastroesophageal reflux disease.

Although the prevalence of gastroesophageal reflux disease (GERD) used to be lower in East Asia as compared to Western countries, it has recently been increasing, most likely due to the socioeconomic development in the East. The prevalence of both GERD and functional gastrointestinal disorders (FGIDs) ranges between 10% and 25% worldwide and there are distinct subgroups of patients with overlapping of GERD and FGIDs. However, the true prevalence of an overlap between GERD and FGIDs can be determined only when a formal pathophysiological evaluation has been performed. Nocturnal reflux symptoms have a significant impact on patients' sleep quality and quality of life. Although proton pump inhibitors (PPIs) can improve both reflux and sleep-related symptoms, the relationship between nocturnal reflux events and sleep disturbance is not fully understood. GERD plays an important role in the pathogenesis of lung fibrosis, and PPIs or fundoplication may decrease the likelihood of pulmonary exacerbation or even improve pulmonary function. Refractory reflux symptoms without esophagitis have become one of the most common presentations of GERD in gastroenterology clinics. There are several new medical therapies, and endoscopic as well as laparoscopic techniques that have been increasingly used in these patients. The selection of options should be tailored and individualized based on the pathophysiology of refractory GERD.