[Application of the recommendations of the conference of consensus in front of symptoms ENT, respiratory or thoracic pains considered as due to a gastroesophageal reflux disease]. / Application des recommandations de la conférence de consensus devant des symptômes ORL, respiratoires ou des douleurs thoraciques considérés comme dus à un reflux gastro-œsophagien.

AIMS: The primary objectives of this observatory were: (1) to assess the prevalence of extradigestive symptoms (EDS) (asthma, pharyngeal pain, chronic hoarseness, nocturnal breathlessness, chronic or nocturnal cough, non-cardiac chest pain) which are suspected of being associated with gastro-oesophageal reflux (GERD) in a population consulting in general practice; (2) to compare the diagnostic and therapeutic approach adopted initially and at follow-up to the recommendations of the French-Belgian Consensus Conference on adult GERD (1999). METHODS: The survey was conducted among 578 general practitioners (GPs). All EDS were investigated in patients (≥ 18 y.o.) consulting over 3 days. Only patients considered a priori as having GERD related EDS were included in study. At each visit (initial and at 1 and 4 months), the diagnostic and therapeutic approach was analyzed, scored, and the GP's certainty regarding the accountability of GER in the EDS rated using the visual analogue scale (VAS). The criteria used by GPs to evaluate GER accountability as certain or doubtful were examined. RESULTS: Out of 33,487 consulting patients, 14% presented EDS (cough: 6.7%; ENT symptoms: 7.7%; chest pain: 2.3%). Among patients presenting EDS, 22% (1063) were included in the study based on suspicion of GERD, whereas 45% (481) had neither history nor digestive symptoms typically associated with GERD. The diagnostic approach did not vary whether the patient presented typical EDS associated symptoms (A+) or not (A-): 83.7% of patients (A+) versus 86.5% (A-) immediately received acid reflux treatment; 4.6% (A+) versus 7.9% (A-) underwent additional testing and 5.2% (A+) versus 4.4% (A-) were referred to a specialist. In 87% of cases, acid reflux treatment included a proton pump inhibitor (PPI) (half-dose: 47.2%, standard dose 50.3%, double dose 2.5%); in 8.1% of patients initial acid reflux treatment included an H2 antagonist while in 3.2% of patients treatment included prokinetic drugs. At 4 months of follow-up, GERD accountability was considered certain in 74.7% of the patients included in the assessment (794/1063). The GPs opinion was based on response to acid reflux treatment in 92% of cases, on endoscopy in 6.7% of cases, on pH monitoring in 0.3% of cases and on a specialist's opinion in 6% of cases. CONCLUSION: There is a considerable difference between the recommendations of the French-Belgian Consensus Conference on adult GERD and the practices observed in general medicine. The diagnostic and therapeutic approaches were empirical with recourse to additional exams in less than 10% of cases. The degree of certainty as to GERD accountability was based primarily on response to PPI treatment.

Gastroesophageal reflux disease: impact on work productivity and daily-life activities of daytime workers. A French cross-sectional study.

BACKGROUND: Few studies have evaluated the impact of gastroesophageal reflux disease symptoms on work productivity and no French data are available. AIM: To compare the impact of typical symptoms of nocturnal vs diurnal gastroesophageal reflux disease on work productivity and daily activities. METHODS: A French prospective, multicenter, observational study was performed in primary care setting. Patient characteristics, symptomatology and treatment were reported. Work productivity loss was assessed using the work productivity and activity impairment questionnaire, predictors were identified using multivariate regression models, and estimated cost was calculated. RESULTS: 716 eligible patients (mean age: 46.3 years) were included by 407 physicians. Nocturnal symptoms were reported in 50.8% of patients and exclusively diurnal symptoms in 49.2%. Mean work productivity and daily activities decreased by 31.4% and 32.6%, respectively (both p<0.001). Work productivity was influenced by symptom intensity, diurnal symptoms occurrence, regurgitation and diurnal sleepiness. The mean associated cost per patient/week (€313) was higher in patients with diurnal symptoms (without (€346) or with nocturnal (€312) symptoms) than in patients with exclusive nocturnal symptoms (€253) (p<0.001). CONCLUSION: Gastroesophageal reflux disease incurs high work productivity loss especially in patients with diurnal symptoms. Further medico-economic analyses are needed to estimate the cost effectiveness ratio according to therapeutic strategies.

[Premalignant gastric lesions (except lymphomas)]. / Etats et lésions précancéreux de l'estomac (en dehors des lymphomes).

Atrophic gastritis, intestinal metaplasia, autoimmune corpus atrophic gastritis, gastric remnant man 15 years after gastrectomy, hyperplastic or adenoma polyps and gastric ulcer are conditions associated with an increased risk of gastric carcinoma of intestinal or diffuse type. The role of Helicobacter pylori infection is major but the usefulness of H. pylorieradication to revert precancerous lesions is questionable. Except for patients with dysplasia, no consensus exists for endoscopic surveillance of these premalignant conditions in countries with low incidence of gastric cancer.

[Gastric polyps]. / Polypes gastriques.

Gastric polyps exist in a wide variety of types, most often benign. Endoscopic discovery of gastric polyps necessitates biopsies - not only of the lesion but also of the antral and fundic mucosa to determine the therapeutic strategy and subsequent surveillance. Fundic gland polyps are the most frequent type; they are asymptomatic with no malignant potential. They require neither treatment nor surveillance. Hyperplastic polyps, adenomas and tumors must be totally resected. Biopsies alone are insufficient to assess the extent of malignancy of adenomas and of hyperplastic polyps more than 5 mm in diameter. These polyps are associated with an elevated frequency of precancerous alterations of the gastric mucosa and consequently by an elevated risk of synchronous or metachronous cancer. Eradication of Helicobacter pylorus may reduce the risk of metachronous gastric cancer and recurrence after resection. Carcinoid tumors of the fundus most often occur in patients with hypergastrinemia during atrophic gastritis of autoimmune origin; they are not serious. The advantages and procedures for endoscopic surveillance of patients with a precancerous condition of the gastric mucosa have not yet been clearly established in populations with a low incidence of cancer.

Applicability and efficacy of qualifying criteria for an appropriate use of diagnostic upper gastrointestinal endoscopy.

UNLABELLED: Appropriate indication for upper gastrointestinal endoscopy (UGE) may be facilitated by referring to qualifying criteria such as those devised by the European Panel (EPAGE) and French Experts (ANAES). This prospective study evaluates the applicability and efficacy of these criteria in clinical practice. PATIENTS AND METHODS: A total of 522 patients was included (55% inpatients, 57% male, mean age 55 years). Appropriateness of referral was evaluated using EPAGE and ANAES criteria sets by a single independent expert. RESULTS: EPAGE criteria were applicable in 71% of cases. Indications for UGE were appropriate, inappropriate and uncertain in 62%, 27% and 11% respectively; 74%, 16% and 10% of clinically significant lesions detected by UGE were disclosed in patients having appropriate, inappropriate and uncertain indications respectively. ANAES criteria were applicable in 81% of cases. Indications for UGE were appropriate in 74%, inappropriate in 26%; 76% and 24% of clinically significant lesions detected by UGE were disclosed in patients having appropriate and inappropriate indications respectively. Whatever the criteria set used, all cancers and most of the severe lesions were observed in patients with appropriate indications: those patients were more often in-patients and were significantly older than patients belonging to the inappropriate group. CONCLUSION: Reference to EPAGE and ANAES qualifying criteria facilitates patient selection for UGE. Final decision must however rely upon practitioner advice. ANAES criteria are significantly more often applicable than EPAGE ones. However EPAGE referential when applicable is more predictive of the UGE findings.

[New-generation proton pump inhibitors: progress in the treatment of peptic acid diseases?]. / Les nouveaux inhibiteurs de la pompe à protons, un progrès dans la prise en charge des maladies acido-peptiques?

EFFECTS AND INCONVENIENCIES OF THE OLDER PRODUCTS: The proton pump inhibitors (PPIs) are now universally considered the treatment of choice for management of gastric-acid-related diseases, mainly gastro-oesophageal reflux disease (GERD). These drugs share similar properties: general structure, acid-activation step, covalent binding to the proton pump of the gastric parietal cell via the production of covalent disulphide bonds, relatively stable inhibition of H+,K+-ATPase. However, the older PPIs (omeprazole, lansoprazole et pantoprazole) have notable limitations. These drugs exhibit substantial interpatient variability and may have significant interactions with other drugs. These first-generation PPIs also do not achieve a rapid and sustained suppression of gastric acid, leading to the development of new acid-pump antagonists. The new-generation PPIs, esomeprazole and rabeprazole, offer several pharmacokinetic advantages: lower oxidative hepatic metabolism rate via the CYP 2C19 reducing the activity variations due to genetic polymorphisms and decreasing the risk of significant drug-drug interactions (advantages mainly for rabeprazole), lower metabolic clearance of esomeprazole (S-enantiomer of omeprazole) increasing plasma concentrations and acid suppression of this new PPI, higher accumulation of rabeprazole in the parietal cell due to its higher pKa. Gastric pH studies and therapeutic trials have demonstrated significant advantages of esomeprazole and rabeprazole compared with the older PPIs, which omeprazole is the prototype: a greater inhibition of acid secretion, a more rapid onset of action to provide reflux symptoms relief over 24 hours with lower GERD-related cost for rabeprazole, a sustained acid suppression, cost-effectiveness advantages for esomeprazole in the healing and maintenance of erosive esophagitis compared with lansoprazole, reduced potential for clinically significant drug-drug interactions with rabeprazole compared with omeprazole and esomeprazole. Due to their properties, esomeprazole and rabeprazole are the best candidates for "on demand" treatment of GERD.