Latin American consensus on diagnosis of gastroesophageal reflux disease.

BACKGROUND: Diagnosing gastroesophageal reflux disease (GERD) can be challenging given varying symptom presentations, and complex multifactorial pathophysiology. The gold standard for GERD diagnosis is esophageal acid exposure time (AET) measured by pH-metry. A variety of additional diagnostic tools are available. The goal of this consensus was to assess the individual merits of GERD diagnostic tools based on current evidence, and provide consensus recommendations following discussion and voting by experts. METHODS: This consensus was developed by 15 experts from nine countries, based on a systematic search of the literature, using GRADE (grading of recommendations, assessment, development and evaluation) methodology to assess the quality and strength of the evidence, and provide recommendations regarding the diagnostic utility of different GERD diagnosis tools, using AET as the reference standard. KEY RESULTS: A proton pump inhibitor (PPI) trial is appropriate for patients with heartburn and no alarm symptoms, but nor for patients with regurgitation, chest pain, or extraesophageal presentations. Severe erosive esophagitis and abnormal reflux monitoring off PPI are clearly indicative of GERD. Esophagram, esophageal biopsies, laryngoscopy, and pharyngeal pH monitoring are not recommended to diagnose GERD. Patients with PPI-refractory symptoms and normal endoscopy require reflux monitoring by pH or pH-impedance to confirm or exclude GERD, and identify treatment failure mechanisms. GERD confounders need to be considered in some patients, pH-impedance can identify supragrastric belching, impedance-manometry can diagnose rumination. CONCLUSIONS: Erosive esophagitis on endoscopy and abnormal pH or pH-impedance monitoring are the most appropriate methods to establish a diagnosis of GERD. Other tools may add useful complementary information.

Long-term risk of adult overweight and obesity among achalasia patients who underwent Heller Myotomy.

BACKGROUND: It is unknown whether surgically treated achalasia cases regain or surpass their usual weight into obesity or overweight in the long-term post-operative period. Here, we aimed to assess the incidence of overweight/obesity (Ob/Ow) and the risk for reoccurrence up to 48 months post-laparoscopic Heller myotomy (LHM). METHODS: We performed a cohort of 114 achalasia cases undergoing LHM. All patients had a confirmed diagnosis of achalasia and had no added comorbidities. We followed up the body mass index (BMI) at the immediate post-operative period, and at one-, six-, 12-, 24-, and 48 months after LHM. We measured the incidence of Ob/Ow and its reoccurrence risk with Cox regression. KEY RESULTS AND CONCLUSIONS: In the immediate post-operative period, the incidence of Ob/Ow was significantly less than the usual BMI (before the onset of symptoms) (28.2% vs 66.3%). From the sixth to the 48th month, there was a progressive increase in the incidence of Ob/Ow and at this timepoint the percent of Ob/Ow was not statistically different from the usual BMI. The most significant hazard for Ob/Ow reoccurrence in the long term following LHM is a usual BMI with obesity grade I or III and males lacking pre-surgical weight loss. INFERENCES: Achalasia cases undergoing surgical treatment should be monitored closely in the post-operative period for weight regain, regardless of their pre-operative BMI. Notably, males who before the onset of symptoms were obese or overweight are at significantly increased risk of regaining or surpassing their weight, despite most having lost weight pre-surgically.

Endoscopic retrograde cholangiopancreatography in the elderly.

BACKGROUND: Endoscopic retrograde cholangiopancreatography (ERCP) is a widely used technique for the diagnosis and treatment of biliary and pancreatic diseases. OBJECTIVE: To know the complication rate of ERCP in the elderly. PATIENTS AND METHODS: Patient files who underwent ERCP were reviewed and were divided into two groups: aged 65 and older (group 1) and less than 65 years (group 2). Socio-demographic variables, prophylactic antibiotic use, indications for ERCP and outcomes were assessed. RESULTS: Mean age in group 1 was 72.9 years and 41.7 years in group 2. Group 1 had more comorbidity (p < 0.001). The most frequent indication for the procedure was obstructive jaundice in both groups (63% versus 44%; p = 0.002). Malignancy was more frequent as a cause of biliary obstruction in group 1 (45% versus 21%; p < 0.001). ERCP was performed once in 76% in group 1 and 93% in group 2 (p = 0.001). Prophylactic antibiotics were used more frequently in group 1 (84% versus 60%; p < 0.001). There were no differences between groups regarding infectious complications (p = 0.700). There was no difference in mortality rates between groups. CONCLUSION: ERCP is a safe procedure in elderly patients. The elderly frequently have more comorbidity. Nevertheless, the complication and mortality rates did not differ in this study. It is noteworthy that elderly patients received prophylactic antibiotics more frequently than younger patients but infectious complications were not different. The patients should not be excluded from ERCP based on their age.

[Obesity and gastroesophageal reflux disease]. / Obesidad y enfermedad por reflujo gastroesofágico.

INTRODUCTION: Obesity is a condition that has been associated with gastroesophageal reflux disease (GERD), however, a cause-effect relationship has not been established. AIM: To analyze current evidence evaluating the relationship between obesity and GERD, as well as the impact of hypocaloric diets and bariatric surgery in gastroesophageal reflux symptoms. MATERIAL AND METHODS: An electronic search in the MEDLINE was performed, looking for information published during the past 15 years: Cohort studies, case-control studies, case series and case reports, including the following key words: "heartburn", "reflux", "gerd", "reflux esophagitis", "obesity", "overweight", "diet", "bariatric surgery" were analized. RESULTS: Thirty-one articles were included. These studies were classified according to the diagnostic method of GERD (i.e., manometry, 24-hour pH monitoring, esophageal transit, endoscopy) and type of bariatric surgery: Adjustable gastric banding (AGB), vertical banded gastroplasty (VBG), and Roux-en-Y gastric bypass (RYGB), or anti-reflux procedure. CONCLUSIONS: Most studies suggest that obesity is a condition predisposing to the development of GERD. However, there are no studies that correlate the degree of obesity with the symptoms of reflux. Hypotonic lower esophageal sphincter, ineffective esophageal motility and presence of hiatal hernia are the pathophysiological mechanisms proposed as inductors of gastroesophageal reflux among obese patients. AGB and VBG seem to induce postoperative esophagitis in some patients, but RYGB has shown to be effective to control GERD symptoms. Overweight and obesity do not seem to affect the results of antireflux surgery. The impact of body weight loss on GERD following hypocaloric diets requires further investigation.

[Non-erosive gastroesophageal reflux disease. Incidence of clinical forms, characteristics of esophageal exposure to acid and symptomatic correlations]. / Enfermedad por reflujo gastroesofágico no erosiva. Frecuencia de sus variedades clínicas, características de la exposición esofágica al ácido y correlación sintomática.

BACKGROUND: It is estimated that up to 70% of community-based patients with heartburn have no evidence of esophageal mucosal injury or non-erosive gastroesophageal reflux disease (NERD). Studies in NERD patients using esophageal pH monitoring and symptom index (SI) have suggested different subgroups or clinical forms. OBJECTIVE: Our aim was to investigate frequency of different subgroups of patients with NERD according to esophageal pH-monitoring parameters and SI, and to determine esophageal acid exposure characteristics and the relationship between symptoms and acid reflux in NERD. MATERIAL AND METHODS: Patients with heartburn at least 3 times per week during 12 weeks during the last year and negative upper GI endoscopy were studied. All patients were submitted to 24 h esophageal pH-metry and SI was calculated. Patients were classified into three groups: group I, patients with abnormal pH-metry; group II, patients with normal pH-metry and positive SI (> or = 50%), and group III, patients with normal pH-metry and negative SI (< 50%). Total number of reflux episodes, length of episode, % time pH < 4, and Johnson-DeMeester score were evaluated. RESULTS: Three hundred patients, 206 women and 94 men, were included. A total of 137 (46%) were classified in group I, 62 (21%) in group II, and 101 (33%) in group III. There were no significant differences in gender and age among groups. All pH parameters were significantly higher in group I. In group II, there was good correlation between heartburn and acid reflux. Esophageal acid exposure in group III was minimal and there was no relationship among symptoms and acid reflux episodes. CONCLUSIONS: Subjects with NERD represent a heterogeneous group of patients. Three subgroups of patients with NERD were identified by pH-metry and SI; a) patients with abnormal acid exposure; b) patients with hypersensitive esophagus (heartburn with physiologic amounts of acid reflux), and c) patients with no correlation between symptoms and acid reflux.

[Successful esophageal pH monitoring with Bravo capsule in patients with gastroesophageal reflux disease]. / Medición exitosa del pH esofágico con la cápsula Bravo en pacientes con enfermedad por reflujo gastroesofágico.

INTRODUCTION: Esophageal 24-h pH monitoring (24-pH) is the most useful test to diagnose and treat patients with gastroesophageal reflux disease (GERD). The traditional system for 24-pH requires transnasal introduction of a catheter with pH sensors. This technique produces discomfort, inconvenience and interference with daily activity. Recently, the Bravo pH system has been proposed as an alternative and promising method for 24-pH. In this study, the initial experience in Mexico with this system is reported. OBJECTIVE: To evaluate safety, tolerability and performance of the pH Bravo capsule in patients with GERD. MATERIALS AND METHODS: Patients with GERD symptoms at least twice a week during the last three months, with indication for 24-pH were evaluated. pH Bravo capsule was placed 6 cm above squamocolumnar junction (SCJ). Symptoms, quality and duration of pH tracings, capsule detachment and patient global satisfaction were evaluated. RESULTS: Eleven patients (nine female, two male) mean age 42 years (range 26-62 years), two with erosive and nine with non-erosive GERD were studied. pH capsule was correctly positioned at 6 cm above SCJ in all patients. Nine patients noted a mild foreign body sensation (especially while eating) and four had mild chest pain; two patients had no discomfort. Capsule detachment occurred spontaneously in all patients on day 10. pH record for > 43 h was obtained in the 11 patients. There were no differences in pH parameters between days 1 and 2. Two patients with normal acid exposure on day 1 had abnormal pH parameters on day 2. CONCLUSIONS: Esophageal pH monitoring with Bravo capsule is a safe, reliable and tolerable method in patients with GERD. Extended pH recordings increases abnormal esophageal acid exposure detection in patients with this disease.

Open, randomized multicenter comparative trial of rabeprazole, ofloxacin and amoxicillin therapy for Helicobacter pylori eradication: 7 vs. 14 day treatment.

BACKGROUND: Because of the increasing resistance to clarithromycin and metronidazole, two of the antibiotics used for the eradication of Helicobacter pylori, new therapeutic alternatives are needed. The aim of this study was to determine the efficacy of a randomized, comparative trial of 7 vs. 14-day triple treatment with rabeprazole, ofloxacin and amoxicillin for H. pylori eradication. MATERIAL AND METHODS: The present authors studied 76 dyspeptic patients infected with H. pylori diagnosed by both histology and a rapid urease test. Patients were randomized to receive rabeprazole (20 mg b.i.d.), plus ofloxacin (400 mg b.i.d.) and amoxicillin (1000 mg b.i.d.) for 7 days (group 1) vs. 14 days (group 2) and were followed by 6 weeks. Eradication was assessed 4 weeks after completing the course of study treatment by the (14)C-urea breath test. Per protocol and intention-to-treat eradication rates were determined. RESULTS: For the intention to treat analysis, the eradication rate was 62.2% for group 1 and 92.3% for group 2 (p =.004). For the per protocol analysis, eradication rate for group 1 was 63.9% and for group 2 was 97.3% (p =.001). CONCLUSIONS: Triple therapy with rabeprazole, amoxicillin and ofloxacin by 14 days was efficient for H. pylori eradication and therefore deserves further study. The same regimen prescribed for 7 days had a significantly lower and unacceptable cure rate and should not be used.

Endoscopic retrograde cholangiopancreatography in the elderly / Colangiopancreatografía endoscópica retrógrada en el adulto mayor

Background. Endoscopic retrograde cholangiopancreatography (ERCP) is a widely used technique for the diagnosis and treatment of biliary and pancreatic diseases. Objective. To know the complication rate of ERCP in the elderly. Patients and methods. Patient files who underwent ERCP were reviewed and were divided into two groups: aged 65 and older (group 1) and less than 65 years (group 2). Sociodemographic variables, prophylactic antibiotic use, indications for ERCP and outcomes were assessed. Results. Mean age in group 1 was 72.9 years and 41.7 years in group 2. Group 1 had more comorbidity (p < 0.001). The most frequent indication for the procedure was obstructive jaundice in both groups (63% versus 44%; p = 0.002). Malignancy was more frequent as a cause of biliary obstruction in group 1 (45% versus 21%; p < 0.001). ERCP was performed once in 76% in group 1 and 93% in group 2 (p = 0.001). Prophylactic antibiotics were used more frequently in group 1 (84% versus 60%; p < 0.001). There were no differences between groups regarding infectious complications (p = 0.700). There was no difference in mortality rates between groups. Conclusion. ERCP is a safe procedure in elderly patients. The elderly frequently have more comorbidity. Nevertheless, the complication and mortality rates did not differ in this study. It is noteworthy that elderly patients received prophylactic antibiotics more frequently than younger patients but infectious complications were not different. The patients should not be excluded from ERCP based on their age.

Introducción. La colangiopancreatografia retrógrada endoscópica (CPRE) es un procedimiento ampliamente utilizado para el diagnóstico y tratamiento de las enfermedades biliares y pancreáticas. Objetivo. Conocer la frecuencia de complicaciones de la CPRE en los adultos mayores. Pacientes y métodos. Se revisaron los expedientes clínicos de pacientes que se sometieron a CPRE y se dividieron en dos grupos: de 65 años o mayores (grupo 1) y menores de 65 años (grupo 2). Se documentaron variables sociodemográficas, uso de antibióticos profilácticos, indicación de la CPRE y evolución. Resultados. El promedio de edad fue de 72.9 años en el grupo 1 y 41.7 años en el grupo 2. El grupo 1 presentó mayor frecuencia de comorbilidad (p < 0.001). La indicación más frecuente para la realización del procedimiento en ambos grupos fue la ictericia obstructiva (63 vs. 44%; p = 0.002). El cáncer fue más frecuente causa de obstrucción en el grupo 1 (45 vs. 21%; p < 0.001). La CPRE se realizó una vez en 76% del grupo 1 y en 93% en el grupo 2 (p = 0.001). Los antibióticos profilácticos se utilizaron con mayor frecuencia en el grupo 1 (84 vs. 60%; p < 0.001). Sí bien, no hubo diferencias en relación con la frecuencia de complicaciones infecciosas (p = 0.700). No hubo diferencias en mortalidad entre los dos grupos. Conclusión. La CPRE es un procedimiento seguro para los adultos mayores. Los adultos mayores frecuentemente presentan mayor comorbílídad. Sin embargo, la frecuencia de complicaciones y mortalidad no fue diferente en este estudio. Es importante señalar que los adultos mayores recibieron con mayor frecuencia antibióticos profilácticos que los pacientes de menor edad, pero la frecuencia de complicaciones infecciosas no fue diferente. No debe excluirse a los pacientes de la CPRE por su edad.

Obesidad y enfermedad por reflujo gastroesofágico / Obesity and gastroesophageal reflux disease

INTRODUCTION: Obesity is a condition that has been associated with gastroesophageal reflux disease (GERD), however, a cause-effect relationship has not been established. AIM: To analyze current evidence evaluating the relationship between obesity and GERD, as well as the impact of hypocaloric diets and bariatric surgery in gastroesophageal reflux symptoms. MATERIAL AND METHODS: An electronic search in the MEDLINE was performed, looking for information published during the past 15 years: Cohort studies, case-control studies, case series and case reports, including the following key words: "heartburn", "reflux", "gerd", "reflux esophagitis", "obesity", "overweight", "diet", "bariatric surgery" were analized. RESULTS: Thirty-one articles were included. These studies were classified according to the diagnostic method of GERD (i.e., manometry, 24-hour pH monitoring, esophageal transit, endoscopy) and type of bariatric surgery: Adjustable gastric banding (AGB), vertical banded gastroplasty (VBG), and Roux-en-Y gastric bypass (RYGB), or anti-reflux procedure. CONCLUSIONS: Most studies suggest that obesity is a condition predisposing to the development of GERD. However, there are no studies that correlate the degree of obesity with the symptoms of reflux. Hypotonic lower esophageal sphincter, ineffective esophageal motility and presence of hiatal hernia are the pathophysiological mechanisms proposed as inductors of gastroesophageal reflux among obese patients. AGB and VBG seem to induce postoperative esophagitis in some patients, but RYGB has shown to be effective to control GERD symptoms. Overweight and obesity do not seem to affect the results of antireflux surgery. The impact of body weight loss on GERD following hypocaloric diets requires further investigation.

Manometría esofágica en la enfermedad por reflujo gastroesofágico. ¿Incompetencia del esfínter esofágico inferior o dismotilidad esofágica? / Esophageal manometry in gastroesophageal reflux disease. Lower esophageal sphincter incompetence or esophageal dismotility?

Antecedentes. Tradicionalmente se ha considerado a la incompetencia del esfínter esofágico inferior (IEEI), como el hallazgo más común en los pacientes con enfermedad por reflujo gastroesofágico (ERGE)- Recientemente se ha informado que la dismotilidad esofágica (DE) o peristalsis anormal, es más prevalente en este grupo de pacientes. Objetivo. Comparar la prevalencia de la IEEI con la DE en paciente con ERGE. Método. Se estudiaron pacientes con esofagitis grado II o mayor por endoscopia y exposición esofágica anormal al ácido, determinada por pH-metría. Se realizó manometría esofágica estacionaria y se determinó la frecuencia de IEEI definida por: a) presión basal del EEI < 10 mmHg, b) longitud del EEI < 2 cm, y c) segmento intraabdominal del EEI < 1 cm; y de DE por la presencia de : a) más del 30 por ciento de ondas peristálticas con amplitud menor de 30 mmHg, o 2 más del 10 por ciento de ondas simultáneas en el esófago distal. Resultados. Se estudiaron 37 pacientes con ERGE, 27 mujeres y 10 hombres con edad promedio de 43.6 años. Tuvieron DE 12 pacientes, (32.4 por ciento), cinco (13.5 por ciento) presentaron IEEI. De estos 17, cuatro presentaron ambas alteraciones. Fueron normales 15 pacientes (40.5 por ciento) y en 5 (13.5 por ciento), la presión del EEI se encontró elevada. Conclusiones. La DE es más frecuente que la IEEI en el estudio manométrico de los pacientes con ERGE