Whole-course management strategies for gastroesophageal reflux disease: an evidence mapping study based on clinical practice guidelines / 中华胃肠外科杂志

Gastroesophageal reflux disease (GERD) is one of the most common digestive diseases with high incidence, complicated clinical symptoms, difficulties in standard treatment, and heavy medical burden. At present, some GERD-relevant clinical practice guidelines (CPGs) have been issued by different countries and academic organizations, but some recommendations were inconsistent, which has caused some problems for the current clinical whole-course management of GERD. To summarize the relevant evidence among the CPGs on GERD and formulate the whole- course management strategies, we included GERD-relevant CPGs published or updated after 2010 by searching websites of guidelines, relevant professional societies, and electronic databases. We extracted the recommendations and summarized the evidence from the aspects of symptoms, epidemiology, diagnosis and treatment, which was presented in the form of evidence mapping. We included 24 CPGs, including three in Chinese and 21 in English. The clinical practice management strategies of GERD were formulated based on the evidence from the aspects of clinical symptoms, diagnostic methods, medical treatment, anti-reflux surgery and endoscopic treatment, psychological treatment, and traditional Chinese medicine treatment.

Tratamiento endoscópico para el reflujo gastroesofágico / Endoscopic treatment of gastroesophageal reflux

Resumen Durante las últimas 2 décadas se han desarrollado una serie de nuevos tratamientos endoscópicos para el tratamiento de la enfermedad por reflujo gastroesofágico (ERGE) como alternativas al tratamiento médico o funduplicatura quirúrgica. Estos dispositivos incluyen aplicación de tratamiento por radiofrecuencia (Stretta), plicatura endoscópica (EndoCinch, Plicator, Esophyx, MUSE) e inyección o implantación de biomateriales (Enteryx, Gatekeeper, Plexiglas, Duragel). Su objetivo es el alivio de los síntomas creando una barrera anatómica antirreflujo. En esta revisión del tema consideramos artículos indexados en Pubmed, Medline y Scielo en los últimos 10 años revisando un total de 55 trabajos. Evaluamos críticamente los resultados reportados, faltan datos a largo plazo superiores a 10 años. Estos procedimientos reducen el uso de inhibidores de la bomba de protones en cerca del 50%. Evaluaciones subjetivas reportan mejoría de la calidad de vida y satisfacción del paciente. Sin embargo, la evaluación objetiva con endoscopia, manometría, radiología y pHmetría son escasos y si los hay, no muestran cambios significativos. No existe evidencia convincente para adoptar estos métodos como tratamiento definitivo y, por lo tanto, la fundoplicatura por vía laparoscópica sigue siendo el estándar de oro para el tratamiento de la enfermedad por reflujo gastroesofágico.

During the last 2 decades, new endoscopic treatments have been developed for the treatment of gastroesophageal reflux disease (GERD) as alternatives to medical treatment or surgical fundoplication. These devices include application of radiofrequency treatment (Stretta), endoscopic plication (EndoCinch, Plicator, Esophyx, MUSE) and injection or implantation of biomaterials (Enteryx, Gatekeeper, Plexiglas, Duragel). Its objective is the relief of symptoms by creating an anatomical anti-reflux barrier. In this review, we consider articles indexed in Pubmed, Medline and Scielo in the last 10 years, reviewing a total of 55 papers, we analyse critically the reported results, although long-term data greater than 5 or 7 years are lacking. These procedures reduce the use of proton pump inhibitors by about 50%. Subjective evaluations report improvement in quality of life and patient satisfaction. However, objective evaluation with endoscopy, manometry, radiology and pHmetry are scarce and if there are, they do not show significant changes. There is no convincing evidence to adopt these methods as definitive treatment. Therefore, laparoscopic fundoplication is the gold standard for the treatment of gastroesophageal reflux disease.

Recomendaciones para el diagnóstico y tratamiento de reflujo gastroesofágico en pediatría / Recommendations for the diagnosis and treatment of gastroesophageal reflux in childhood

El reflujo gastroesofágico es una situación frecuente en el primer año de vida. En ausencia de signos y síntomas de alarma, se lo considera fisiológico. No requiere estudios y puede ser abordado por el pediatra con medidas no farmacológicas. La enfermedad por reflujo (definidaporsíntomasmolestosocomplicaciones) debe ser manejada por el gastroenterólogo. Los exámenes complementarios tienen indicaciones precisas y el tratamiento incluye medidas no farmacológicas, farmacológicas y quirúrgicas (si fuera necesario). Nuestro objetivo es describir los diferentes métodos diagnósticos, sus indicaciones y limitaciones, así como los recursos terapéuticos disponibles, incluidas las indicaciones y los efectos adversos

Gastro esophageal reflux is a frequent condition in infants. In the absence of warning symptoms and signs, it is considered physiologic. No exam is required and a non-pharmacologic approach can be instituted by pediatricians. Gastro esophageal reflux disease is characterized by troublesome symptoms or complications and should be managed by a pediatric gastroenterologist. Diagnostic tests have accurate indications and treatment includes pharmacologic and non-pharmacologic measures as well as surgery. Our objective is to describe the different diagnostic methods, their indications and limitations as well as the therapeutic resources available, including indications and adverse effects.

Práticas de médicos brasileiros no manejo de sintomas sugestivos de doença do refluxo gastroesofágico: uma avaliação multidisciplinar / Brazilian physicians' practices on the management of symptoms suggesting gastroesophageal reflux disease: a multidisciplinary survey

ABSTRACT BACKGROUND: Clinical guidelines are available to steer decisions regarding diagnosis, management and treatment of gastrointestinal disorders. Despite this, variations in physician's practices regarding gastroesophageal reflux disease (GERD) symptoms are well described in the literature. OBJECTIVE: To describe practices of physicians from different specialties on the management of patients with typical symptoms of GERD (heartburn and regurgitation) in a Brazilian sample. METHODS: National online survey enrolling a sample of general practitioners, gastroenterologists, cardiologists and otolaryngologists. The survey was conducted from August 6th to September 12th, 2018. Subjects answered a structured questionnaire addressing variables regarding physicians' profile (age, sex, specialty, practice setting, years in practice, type of medical expense reimbursement), their patients characteristics and prescribing behaviors. RESULTS: The final weighted sample was comprised of 400 physicians, 64% male, with an average of 15 years of experience. Physicians' estimates of gastroesophageal symptoms prevalence among their pool of patients was 37.6% for the total sample, reaching 70.3% among gastroenterologists. The medical specialty with lower average percentage of patients presenting gastroesophageal symptoms was otolaryngology (24.5%). Physicians reported that they request ancillary tests for 64.5% of patients with GERD typical symptoms. The most common diagnostic test was endoscopy (69.4%), followed by video nasolaryngoscopy (16.6%). The percentage of patient to whom endoscopy is performed was significantly higher among gastroenterologists and general practitioners as compared to otolaryngologists and cardiologists, while video nasolaryngoscopy is markedly more frequent among otolaryngologists. In terms of therapeutic options, the most frequently reported strategy was lifestyle modifications followed by proton pump inhibitors. CONCLUSION: Overall patients' profile and patterns of GERD diagnosis and management seem different between gastroenterologists, general practitioners, otolaryngologists, and cardiologists. Clinical guidelines should address this variability and include other medical specialties besides gastroenterologists in their scope.

RESUMO CONTEXTO: Diretrizes clínicas estão disponíveis para orientar decisões sobre diagnóstico, manejo e tratamento de desordens gastrointestinais. Apesar disso, variações nas práticas relacionadas aos sintomas de doença do refluxo gastroesofágico (DRGE) são observadas na literatura. OBJETIVO: Descrever os conhecimentos e práticas relacionados ao manejo de pacientes com sintomas típicos de DRGE (pirose e regurgitação) em uma amostra brasileira de médicos de especialistas e não especialistas. MÉTODOS: Inquérito nacional online investigando a conduta frente ao diagnóstico de DRGE em uma amostra de médicos generalistas, gastroenterologistas, cardiologistas e otorrinolaringologistas. O inquérito foi conduzido entre 6 de agosto e 12 de setembro de 2018. Os sujeitos responderam a um questionário estruturado avaliando variáveis relacionadas ao perfil dos médicos (idade, sexo, especialidade, contexto de prática, anos de experiência, tipo de reembolso de despesas médicas), características dos pacientes e comportamentos de prescrição. RESULTADOS: A amostra final ponderada foi composta por 400 médicos, 64% homens, com um tempo médio de experiência de 15 anos. A estimativa dos médicos a respeito da prevalência de sintomas gastroesofágicos entre seus pacientes foi de 37,6% para a amostra total, alcançando 70,3% entre gastroenterologistas. A especialidade médica com menor percentual de pacientes apresentando sintomas gastroesofágicos foi otorrinola­ringologia (24,5%). Os médicos requisitaram exames complementares em 64,5% dos pacientes com sintomas típicos de DRGE. O exame diagnóstico mais frequente foi endoscopia (69,4%), seguida de nasolaringoscopia (16,6%). O percentual de pacientes nos quais uma endoscopia é realizada é significativamente maior entre gastroenterologistas e médicos generalistas, quando comparado a otorrinolaringologistas e cardiologistas, enquanto nasolaringoscopia é marcadamente mais frequente entre otorrinolaringologistas. Em termos de opções terapêuticas, a estratégia mais frequentemente reportada foi modificações no estilo de vida, seguida de inibidores da bomba de prótons. CONCLUSÃO: De modo geral, o perfil de pacientes e os padrões de diagnóstico e manejo de DRGE parecem diferir entre gastroenterologistas, médicos generalistas, otorrinolaringologistas e cardiologistas. Diretrizes clínicas devem abordar esta variabilidade e incluir outras especialidades médicas além de gastroenterologistas em seu escopo.

Acupoint selection rules in treating gastroesophageal reflux disease with acupuncture in China based on data mining / 中国针灸

OBJECTIVE@#To analyze the rules of acupoint selection in the treatment of gastroesophageal reflux disease in China using data mining technology.@*METHODS@#The published literature of treating gastroesophageal reflux disease with acupuncture was retrieved from electronic databases from January 1, 1983 to December 1, 2019, including SinoMed, CNKI, Wanfang and VIP database. Acupuncture prescription database was established, and the rules of acupoint selection were explored by statistical software SPSS 20.0 and SPSS Modeler 18.0.@*RESULTS@#A total of 92 articles were included into this analysis, involving 92 acupuncture prescriptions, 76 acupoints. The total frequency of using these acupoints reached 549 times. Zhongwan (CV 12) was the most frequently used acupoint; the often selected meridians were conception vessel, stomach meridian, governor vessel, bladder meridian; the acupoints located at the abdomen, lower limbs and back were commonly selected; crossing points in the specific acupoints were commonly selected; the most frequently used group was Zusanli (ST 36)-Zhongwan (CV 12) and Neiguan (PC 6).@*CONCLUSION@#Treating gastroesophageal reflux disease by acupuncture in China is dominated by

Relación del reflujo gastroesofágico y manifestaciones respiratorias, desde el punto de vista de la gastroenterología pediátrica / Relationship between gastroesophageal reflux and respiratory manifestations, from the pediatric gastroenterologist point of view

Gastroesophageal reflux is a frequent condition in the daily life of infants and older children. When reflux causes symptoms, it is called gastroesophageal reflux disease. Different extraesophageal symptoms have been frequently attributed to gastroesophageal reflux, however, new diagnostic techniques available, such as pHmetry with impedance measurement, have allowed us to evaluate and eventually dismiss such relationships. In this article we review the relationship between gastroesophageal reflux and laryngeal pathology, chronic cough, asthma and aspiration. In general terms, the empirical treatment of a presumed reflux is not recommended in asymptomatic patients, in whom its presence is not demonstrated by techniques such as pHmetry with impedance, given that therapeutic response is low and similar to placebo, with potential adverse effects.

El reflujo gastroesofágico es una condición frecuente en la vida diaria de lactantes y niños mayores. Cuando produce síntomas, se denomina enfermedad por reflujo gastroesofágico. Se ha atribuido frecuentemente diferentes síntomas extraesofágicos al reflujo, sin embargo, nuevas técnicas diagnósticas disponibles, como la pHmetría con medición de impedanciometría, han permitido evaluar y eventualmente descartar tales asociaciones. En este artículo se revisa la relación entre el reflujo gastroesofágico y patología laríngea, tos crónica, asma y aspiración. En términos generales, no se recomienda el tratamiento empírico de un supuesto reflujo en pacientes asintomáticos, en quienes tampoco esté demostrada su presencia por técnicas como la pHmetría con impedanciometría, dado que la respuesta terapéutica es baja y similar a placebo, con potenciales efectos adversos.

Perspectiva histórica do tratamento clínico da doença do refluxo gastroesofágico / Historical perspective of gastroesophageal reflux disease clinical treatment

ABSTRACT BACKGROUND: Gastroesophageal reflux disease (GERD) is one of the most prevalent gastrointestinal diseases. GERD generates significant impairment in patients' quality of life and it is associated to relevant medical resources utilization. A better understanding of GERD pathophysiology in the past five decades has favored the evolution of therapeutic strategies from non-drug interventions and antacids to more efficacious and safer alternatives. OBJECTIVE: To summarize data about the historical evolution of GERD management in Brazil, focusing on medical therapy and addressing evidence on efficacy and safety of drug classes currently recommended. METHODS: A narrative review was conducted by systematizing information about discoveries on GERD pathophysiology. We also addressed efficacy and safety of medications currently used to reduce symptoms and improve endoscopic healing of esophageal lesions. A structured search on Pubmed was performed to identify systematic reviews and meta-analysis investigating GERD outcomes positively impacted by proton pump inhibitors (PPIs), the first choice of pharmacotherapy for the disease. RESULTS: The chronological development of therapeutic measures for GERD in Brazil evolved from lifestyle interventions with relative poor effect on symptoms related to esophageal acid exposure, particularly heartburn, to effective and safe pharmacological interventions such as histamine H2-receptor antagonists and PPIs. In the present days, some drug classes play a minor role in disease management, namely prokinetics and antacids, due to their reduced efficacy and relevant safety concerns (particularly with prokinetics). The main challenge for prescribers and researchers seems to be finding long-acting acid suppressants strategies able to ameliorate patients' symptoms and quality of life, thereafter, reducing medical resource consumption. The dual delayed-release PPI dexlansoprazole seems to respond for some of the limitations other PPIs have. CONCLUSION: Recognizing the historical evolution of GERD management can help care providers to better understand therapeutic options for their patients, as well as focus on unmet needs that deserve further attention. PPIs are still the first choice therapy, with good evidence in favor of their efficacy, despite some safety concerns. However, as with any medical intervention, it is recommended to prescribe PPIs for patients with clear indication, using adequate dosing and monitoring for adverse events.

RESUMO CONTEXTO: A doença do refluxo gastroesofágico (DRGE) é uma das doenças gastrointestinais mais prevalentes, resultando em limitações significativas na qualidade de vida dos pacientes e, também, relevante utilização de recursos médicos. Um melhor entendimento da fisiopatologia da doença nas últimas cinco décadas tem favorecido a evolução das estratégias de tratamento, desde intervenções não farmacológicas e antiácidos, a alternativas mais eficazes e seguras. OBJETIVO: Resumir os dados sobre a evolução histórica do manejo da DRGE no Brasil, focando na terapia medicamentosa e abordando evidências sobre a eficácia e segurança de classes medicamentosas atualmente recomendadas. MÉTODOS: Uma revisão narrativa foi conduzida para sistematizar informações sobre descobertas na fisiopatologia da DRGE e, também, sobre a eficácia e segurança de medicamentos utilizados atualmente para reduzir os sintomas e melhorar a cicatrização endoscópica de lesões esofágicas. Uma busca estruturada na base de dados Pubmed foi realizada para identificar revisões sistemáticas e metanálises que investigassem desfechos da doença impactados positivamente pelos inibidores da bomba de prótons (IBPs), a primeira escolha farmacológica para a doença. RESULTADOS: O desenvolvimento cronológico das medidas terapêuticas para a DRGE no Brasil evoluiu de modificações no estilo de vida que demonstraram relativamente pouco efeito sobre os sintomas relacionados à exposição esofágico ao ácido, particularmente a azia, a intervenções farmacológicas eficazes e seguras como os anti-histamínicos H2 e os IBPs. Atualmente, algumas classes de medicamentos exercem um papel menor no manejo da doença, procinéticos e antiácidos por exemplo, devido à sua eficácia reduzida e a preocupações relevantes quanto a segurança (particularmente com os procinéticos). O principal desafio para os prescritores e pesquisadores parece ser encontrar estratégias supressoras de ácidos de longa duração capazes de melhorar os sintomas e a qualidade de vida dos pacientes, reduzindo assim o consumo de recursos médicos. O dexlansoprazol, um IBP de liberação retardada dupla, parece responder a algumas limitações que outros IBPs têm. CONCLUSÃO: O reconhecimento da evolução histórica do manejo da DRGE pode auxiliar aos profissionais assistentes a melhor entender as opções terapêuticas para seus pacientes, assim como focar em necessidades não atendidas que necessitem de maior atenção. IBPs ainda são a terapia de escolha inicial, com boas evidências a favor de sua eficácia, apesar algumas questões acerca da segurança de seu uso. No entanto, assim como para qualquer intervenção medicamentosa, é recomendada a prescrição dos IBPs para pacientes com indicação clara, utilizando doses adequadas e monitorando a ocorrência de eventos adversos.

Efecto del envejecimiento en el estudio y manejo de la enfermedad por reflujo gastroesofágico / Effect of aging on the study and management of Gastroesophageal Reflux Disease

The prevalence of Gastroesophageal Reflux Disease (GERD) seems to increase in the elderly population, being more severe and associating more complications than younger subjects. A high frequency of atypical symptoms (chest pain, dysphagia, vomiting, and respiratory symptoms) and less frequently heartburn and / or regurgitation that are of mild intensity are described, due to the decrease of the visceral sensitivity of the esophagus with age, which delays the diagnosis. Factors associated with aging predispose to the development of GERD in the geriatric population: the reduction of salivary flow and bicarbonate secretion, alterations in esophageal motility and the greater frequency of hiatal hernias are some of them. Given the high frequency of complications of reflux (erosive esophagitis, Barrett's esophagus, stenosis and ulcers, and esophageal cancer), elderly patients benefit from an early endoscopic study. Its management must be aggressive and start with changes in lifestyle and dietary modifications. Proton pump inhibitors (PPIs) continue to be the first line of pharmacological treatment as well as in the youngest population. Surgical treatment is reserved in selected patients considering risks/benefits.

La prevalencia de la enfermedad por reflujo gastroesofágico (ERGE) parece aumentar en la población adulto mayor, siendo más severa y asociando más complicaciones que en los sujetos más jóvenes. Clínicamente se caracteriza una alta frecuencia de síntomas atípicos (dolor torácico, disfagia, vómitos, síntomas respiratorios) y menos frecuentemente por pirosis y/o regurgitación que son de leve intensidad, debido a la disminución de la sensibilidad visceral del esófago con la edad, lo que hace retardar el diagnóstico. Factores asociados al envejecimiento predisponen al desarrollo de ERGE en la población geriátrica: la disminución de la secreción salival y de bicarbonato, las alteraciones de la motilidad esofágica y la mayor frecuencia de hernias hiatales, son algunos de ellos. Dada la alta frecuencia de complicaciones del reflujo (esofagitis erosiva, esófago de Barrett, estenosis y úlceras y cáncer de esófago), los pacientes adultos mayores se benefician de un estudio endoscópico precoz. Su manejo debe ser agresivo e iniciar con cambios de estilo de vida y modificaciones dietarias. Los inhibidores de bomba de protones (IBP) siguen siendo la primera línea de tratamiento farmacológico al igual que en la población más joven. El tratamiento quirúrgico queda reservado en pacientes seleccionados considerando riesgos/beneficios.

Pacientes que no responden a prueba con inhibidores de la bomba de protones: diagnóstico y manejo / Patients with symptoms refractory to proton pump inhibitors: diagnosis and management

One third of patients with symptoms of gastro-esophageal reflux disease (GERD) are unresponsive to proton-pump inhibitors (PPIs). Most of them suffer from functional heartburn or other functional pathology. The mechanisms involved include non-acid reflux, aerophagia and belching, reflux hypersensitivity and psychological comorbidities. After ensuring adherence to nonpharmacologic measures and changes in types of PPIs, the initial diagnostic strategy is based on finding erosive esophagitis and rule out eosinophilic esophagitis in endoscopy and prove or rule out abnormal gastro esophageal reflux (GER) and association of symptoms by pH monitoring with or without impedanciometry. After ruling out GERD, the association of symptoms in these tests can direct therapy toward the use of baclofen or pain modulators.

Un tercio de los pacientes con síntomas de enfermedad por reflujo gastro-esofágico (ERGE) no responden a inhibidores de la bomba de protones (IBP). La mayoría de ellos padece una patología esofágica funcional. Los mecanismos implicados incluyen reflujo no ácido, aerofagia y eructos, hipersensibilidad al ácido y comorbilidad psicológica. Luego de asegurar adherencia a medidas no farmacológicas y cambios en tipos de IBP, la estrategia diagnóstica inicial se basa en hallazgo de esofagitis erosiva y descarte de esofagitis eosinofílica en la endoscopia, así como objetivar/descartar RGE patológico y asociación de síntomas mediante pHmetría con o sin impedanciometría. Tras descartar RGE patológico, la asociación de síntomas en estas últimas pruebas pueden dirigir la terapia hacia el uso de baclofeno y moduladores del dolor.

Enfermedad por reflujo gastroesofágico / Gastroesophageal reflux disease

La enfermedad por reflujo gastroesofágico (ERGE) es una de las causas de consulta más frecuentes en atención primaria y en gastroenterología Más el 40 por ciento de la población general experimenta pirosis y regurgitación ocasional debido a ERGE. Es una entidad nosológica compleja, y la fisiología y patogénesis aún no están totalmente aclaradas. Sin embargo, alteraciones a nivel del esfínter esofágico inferior, de la motilidad esofágica o del vaciamiento gástrico pueden producir o empeorar la ERGE. Hay diversos enfoques diagnósticos y terapéuticos; sin embargo, el uso de inhibidores de la bomba de protones a permanencia y la fundoplicatura (cirugía antirreflujo), son las opciones más efectivas

Gastroesophageal reflux disease (GERD) is one of the most frequent causes of consultation in primary care and gastroenterology. Over 40 percent of the general population experiences occasional heartburn and regurgitation due to GERD. It is a complex disease and physiology and pathogenesis are not yet completely defined. However, abnormalities in the lower esophageal sphincter, esophageal motility or gastric emptying can cause or worsen GERD. There are various diagnostic and therapeutic approaches; however, the use of proton-pump inhibitor fundoplication permanence and (antireflux surgery), are the most effective options

Guía de práctica clínica para la enfermedad por reflujo gastroesofágico / Clinical practice guideline for disease caused by gastroesophageal reflux

Objetivo: brindar una guía de práctica clínica basada en la evidencia más reciente para el diagnóstico y tratamiento del reflujo gastroesofágico teniendo en cuenta la efectividad y seguridad de las intervenciones dirigidas a pacientes, personal asistencial, administrativo y entes gubernamentales de cualquier servicio de atención en Colombia. Materiales y métodos: esta guía fue desarrollada por un equipo multidisciplinario con apoyo de la Asociación Colombiana de Gastroenterología, el Grupo Cochrane ITS y el Instituto de Investigaciones Clínicas de la Universidad Nacional de Colombia. Se desarrollaron preguntas clínicas relevantes y se realizó la búsqueda de guías nacionales e internacionales en bases de datos especializadas. Las guías existentes fueron evaluadas en términos de calidad y aplicabilidad; 1 guía cumplió los criterios de adaptación, por lo que se decidió adaptar 3 preguntas clínicas. El Grupo Cochrane realizó la búsqueda sistemática de la literatura. Las tablas de evidencia y recomendaciones fueron realizadas con base en la metodología GRADE. Las recomendaciones de la guía fueron socializadas en una reunión de expertos con entes gubernamentales y pacientes. Resultados: se desarrolló una guía de práctica clínica basada en la evidencia para el diagnóstico y tratamiento de pacientes con reflujo gastroesofágico en Colombia. Conclusiones: el diagnóstico y manejo oportuno de los pacientes con ERGE contribuirá a disminuir la carga de la enfermedad en Colombia, así como de las enfermedades asociadas.

Objective: To provide a clinical practice guideline with the latest evidence for diagnosis and treatment of gastroesophageal reflux for patients, caregivers, administrative and government bodies at all levels of care in Colombia. Materials and Methods: This guide was developed by a multidisciplinary team with the support of the Colombian Association of Gastroenterology, Cochrane STI Group and Clinical Research Institute of the Universidad Nacional de Colombia. Relevant clinical questions were developed and the search for national and international guidelines in databases was performed. Existing guidelines were evaluated quality and applicability. One guideline met the criteria for adaptation, so the group decided to adapt 3 clinical questions. Systematic literature searches were conducted by the Cochrane Group. The tables of evidence and recommendations were made based on the GRADE methodology. The recommendations of the guide were socialized in a meeting of experts with government agencies and patients. Results: An evidence-based Clinical Practice Guidelines for the diagnosis and treatment of gastroesophageal reflux was developed for the Colombian context. Conclusions: The opportune detection and appropriate management of gastroesophageal reflux would contribute to the burden of the disease in Colombia and its associated diseases.

Surfactant Protein A Expression in Chronic Rhinosinusitis and Atrophic Rhinitis

Introduction Surfactant protein A (SP-A) exhibits antimicrobial properties and interacts with a variety of respiratory tract pathogens. Objective The objective of this study was to detect the presence of SP-A and measure its alterations in chronic rhinosinusitis (CRS) and primary atrophic rhinitis (PAR) versus healthy controls. Methods Inferior turbinate and sinus mucosal biopsies were taken from 30 patients with CRS, 30 patients with PAR, and 20 healthy controls. Immunohistochemical staining for SP-A and polymerase chain reaction (PCR) amplification of SP-A messenger RNA were performed on nasal tissue samples. Results Immunostaining localized SP-A to the mucosa and submucosal glands in CRS specimens but failed to localize it in PAR specimens. Quantitative PCR showed a high, statistically significant increase in the SP-A levels of patients with CRS when compared with controls (p < 0.0001) and also demonstrated a significant reduction of SP-A in patients with PAR compared with controls (p < 0.005). Conclusion SP-A is significantly increased in CRS and decreased significantly in PAR and appears to be expressed by respiratory epithelial cells and submucosal glandular elements of the sinonasal mucosa. The potential therapeutic applications of surfactant in the enhancement of mucociliary clearance need to be studied. .

Diagnosis and management of gastroesophageal reflux disease / Diagnóstico e tratamento da doença do refluxo gastroesofágico

INTRODUCTION: Gastroesophageal reflux disease (GERD) is probably one of the most prevalent diseases in the world that also compromises the quality of life of the affected significantly. Its incidence in Brazil is 12%, corresponding to 20 million individuals. OBJECTIVE: To update the GERD management and the new trends on diagnosis and treatment, reviewing the international and Brazilian experience on it. METHOD: The literature review was based on papers published on Medline/Pubmed, SciELO, Lilacs, Embase and Cochrane crossing the following headings: gastroesophageal reflux disease, diagnosis, clinical treatment, surgery, fundoplication. RESULTS: Various factors are involved on GERD physiopathology, the most important being the transient lower esophageal sphincter relaxation. Clinical manifestations are heartburn, regurgitation (typical symptoms), cough, chest pain, asthma, hoarseness and throat clearing (atypical symptoms), which may be followed or not by typical symptoms. GERD patients may present complications such as peptic stenosis, hemorrhage, and Barrett's esophagus, which is the most important predisposing factor to adenocarcinoma. The GERD diagnosis must be based on the anamnesis and the symptoms must be evaluated in terms of duration, intensity, frequency, triggering and relief factors, pattern of evolution and impact on the patient's quality of life. The diagnosis requires confirmation with different exams. The goal of the clinical treatment is to relieve the symptoms and surgical treatment is indicated for patients who require continued drug use, with intolerance to prolonged clinical treatment and with GERD complications. CONCLUSION: GERD is a major digestive health problem and affect 12% of Brazilian people. The anamnesis is fundamental for the diagnosis of GERD, with special analysis of the typical and atypical symptoms (duration, intensity, frequency, triggering and relief factors, evolution and impact ...

INTRODUÇÃO: A doença do refluxo gastroesofágico (DRGE) é, provavelmente, uma das doenças mais prevalentes no mundo que compromete significativamente a qualidade de vida. Sua incidência no Brasil é de 12%, o que corresponde a 20 milhões de indivíduos. OBJETIVO: Atualizar o manuseio da DRGE e as novas tendências no diagnóstico e tratamento, revendo as experiências internacional e brasileira sobre o tema. MÉTODO: Foi realizada revisão da literatura baseada em artigos publicados no Medline/Pubmed, SciELO, Lilacs, Embase e Cochrane cruzando os seguintes descritores: doença do refluxo gastroesofágico, diagnóstico, tratamento clínico, cirurgia, fundoplicatura. RESULTADOS: Vários fatores estão envolvidos na fisiopatologia da DRGE, sendo o mais importante o relaxamento transitório do esfíncter inferior do esôfago. As manifestações clínicas são azia, regurgitação (sintomas típicos), tosse, dor torácica, asma, rouquidão e pigarro (sintomas atípicos), que podem ser seguidos ou não de sintomas típicos. Pacientes com DRGE podem apresentar complicações como estenose péptica, hemorragia e esôfago de Barrett, que é o fator predisponente mais importante para adenocarcinoma. O diagnóstico deve ser baseado na anamnese e os sintomas devem ser avaliados em termos de duração, intensidade, frequência, fatores precipitantes e relevância, padrão de evolução e impacto na qualidade de vida do paciente. O diagnóstico exige confirmação com exames diferentes. O objetivo do tratamento clínico é aliviar os sintomas e o tratamento cirúrgico é indicado para os que necessitam de uso contínuo de drogas, com intolerância ao tratamento clínico prolongado e com complica...

Laryngopharyngeal Reflux and Proton Pump Inhibitors.

Laryngopharyngeal reflux (LPR) refers to the backflow of stomach contents into the throat that is into the hypopharynx.LPR is different from classical GERD. Although PPIs appear to be effective, higher doses for a longer duration are necessary as compared with esophageal GERD disease. In this study we focused on clinical characteristics and role of proton pump inhibitors in Laryngopharyngeal Reflux. Material and Methods: The prospective observational study was done in LPR patients in the Department of ENT and HNS of SKIMS Medical College and Government Medical College Srinagar for a period of 2 years from 2010 to 2012 .Sixty cases were enrolled in the study. LPR was diagnosed on the basis of RFS and RSI. Role of PPI was assessed by the changes of RSI and RFS with Proton pump inhibitors. Results: Total number of patients included in the study were 60, 42 (70%) cases were females, 18 (30%) were males. Frequent clearing of throat was the most common symptom. Mean RSI of all patients was 25.25 before treatment. Significant change in RSI occurred after first 10 weeks of therapy and no further significant change occurred in the next 10 weeks. Most common laryngeal finding was erythema/hyperaemia; Mean RFS of the patients was 13 before treatment with proton pump inhibitors. There was slight response after 10 weeks of therapy in physical findings and significant response after 20 weeks. Conclusion: LPR is a common condition presenting in ENT settings, the symptoms and signs may be complex. PPI are treatment of choice and should be continued for about 5 months because clinical symptoms take about two month to resolve while signs take about 5 months to resolve.

Exacerbations of COPD and symptoms of gastroesophageal reflux: a systematic review and meta-analysis

OBJECTIVE: To examine the relationship between gastroesophageal reflux (GER) and COPD exacerbations. METHODS: We conducted a systematic search of various electronic databases for articles published up through December of 2012. Studies considered eligible for inclusion were those dealing with COPD, COPD exacerbations, and GER; comparing at least two groups (COPD vs. controls or GER vs. controls); and describing relative risks (RRs) and prevalence ratios-or ORs and their respective 95% CIs (or presenting enough data to allow further calculations) for the association between GER and COPD-as well as exacerbation rates. Using a standardized form, we extracted data related to the study design; criteria for GER diagnosis; age, gender, and number of participants; randomization method; severity scores; methods of evaluating GER symptoms; criteria for defining exacerbations; exacerbation rates (hospitalizations, ER visits, unscheduled clinic visits, prednisone use, and antibiotic use); GER symptoms in COPD group vs. controls; mean number of COPD exacerbations (with symptoms vs. without symptoms); annual frequency of exacerbations; GER treatment; and severity of airflow obstruction. RESULTS: Overall, GER was clearly identified as a risk factor for COPD exacerbations (RR = 7.57; 95% CI: 3.84-14.94), with an increased mean number of exacerbations per year (mean difference: 0.79; 95% CI: 0.22-1.36). The prevalence of GER was significantly higher in patients with COPD than in those without (RR = 13.06; 95% CI: 3.64-46.87; p < 0.001). CONCLUSIONS: GER is a risk factor for COPD exacerbations. The role of GER in COPD management should be studied in greater detail. .

OBJETIVO: Examinar a relação entre refluxo gastroesofágico (RGE) e exacerbações da DPOC. MÉTODOS: Foi realizada uma revisão sistemática de artigos publicados até dezembro de 2012 utilizando várias bases de dados. Os critérios de elegibilidade incluíram estudos sobre DPOC, exacerbações da DPOC e RGE que comparavam ao menos dois grupos (DPOC vs. controle ou RGE vs. controle) e descrevendo riscos relativos (RRs), razões de prevalência ou ORs e respectivos IC95% (ou com dados que permitissem o seu cálculo) para a associação entre RGE e DPOC, assim como taxas de exacerbações. Os dados foram coletados com um formulário padronizado que incluía o tipo de estudo; critérios para diagnóstico de RGE; idade e gênero dos participantes; número de participantes; método de randomização; escores de gravidade; métodos de avaliação dos sintomas de RGE; critérios de definição de exacerbação; taxa de exacerbações (hospitalizações, visitas à emergência, consultas não programadas, uso de prednisona e uso de antibióticos); sintomas de RGE no grupo DPOC vs. controles; média de exacerbações da DPOC (com sintomas vs. sem sintomas); frequência anual de exacerbações; tratamento para RGE; e gravidade da obstrução. RESULTADOS: O RGE foi claramente identificado como um fator de risco para exacerbações da DPOC (RR = 7,57; IC95%: 3,84-14,94), com um aumento na média de exacerbações por ano (diferença média: 0,79; IC95%: 0,22-1,36). Houve uma prevalência significativamente maior de RGE em pacientes com DPOC do que naqueles sem DPOC (RR = 13,06; IC95%: 3,64-46,87; p < 0,001). CONCLUSÕES: ...

Manifestações extraesofágicas da DRGE / Extraesophageal manifestations of GERD

A doença do refluxo gastroesofágico é decorrente do fluxo retrógrado de secreção cloridropéptica para o esôfago e órgãos adjacentes, causando um espectro variável de lesões e sintomas. Sua incidência vem aumentando nos últimos anos e sua prevalência estimada na população brasileira é de cerca de 12%. A DRGE tem como manifestações típicas a pirose e a regurgitação, podendo se apresentar com queixas extraesofágicas tais como asma, tosse crônica, dor torácica não cardíaca e sintomas otorrinolaringológicos.

Gastro-oesophageal reflux disease is caused by the retrograde flow of gastric acid-peptic secretion into the esophagus and adjacent organs, causing a variable spectrum of lesions and symptoms. Its incidence has been increasing in recent years and its estimated prevalence in the Brazilian population is about 12%. Typical manifestations of GERD are heartburn and regurgitation, but the disease may present with extraesophageal complaints such as asthma, chronic cough, non-cardiac chest pain and ENT symptoms.

Doença do refluxo gastroesofágico / Gastroesophageal reflux disease

A doença do refluxo gastroesofágico (DRGE) é uma afecção crônica frequente na prática médica, interferindo negativamente na qualidade de vida dos pacientes. Apresenta um amplo espectro de sintomas, classificados como típicos e atípicos, sendo a pirose a principal manifestação. O tratamento inclui medidas comportamentais farmacológicas e eventualmente cirúrgicas

Gastroesophageal reflux disease (GERD) is a common chronic condition that affects negatively the patient's quality of life. Patients with GERD can exhibit a wide variety of symptoms, both typical and atypical. Heartburn is the main clinical presentation. Treatment consists of supportive and pharmacological measures; surgery may eventually be required