Low FODMAPs diet or usual dietary advice for the treatment of refractory gastroesophageal reflux disease: An open-labeled randomized trial.

BACKGROUND: The low FODMAPs (fermentable oligo-, di-, monosaccharides, and polyols) diet improves lower gastrointestinal symptoms. Patients suffering from proton pump inhibitor (PPI) refractory gastroesophageal reflux disease (GERD) have limited treatment options. We investigated the efficacy of a low FODMAPs diet in patients with PPI refractory GERD. METHODS: This multicenter, randomized, open-label study compared the efficacy of a 4-week low FODMAPs diet and usual dietary advice (ie, low-fat diet and head of bed elevation) in patients with symptomatic PPI refractory GERD, defined by a Reflux Disease Questionnaire (RDQ) score >3 and abnormal pH-impedance monitoring on PPIs. The primary endpoint was the percentage of responders (RDQ ≤3) at the end of the diet. RESULTS: Thirty-one patients (55% women, median age 45 years) were included, 16 randomized in the low FODMAPs diet group and 15 in the usual dietary advice group. Adherence to the assigned diet was good, with a significant difference in the FODMAPs intake per day between the low FODMAPs diet (2.5 g) and the usual dietary advice group (13 g) (p < 0.001). There was no difference in response rates (RDQ score ≤3) between the low FODMAPs diet (6/16, 37.5%) and usual dietary advice (3/15, 20%) groups (p = 0.43). Total RDQ score and dyspepsia subscore decreased significantly over time in both groups (p = 0.002), with no difference according to the assigned diet group (p = 0.85). CONCLUSION: Low FODMAPs diet and usual dietary advice have similar but limited beneficial effects on symptoms in patients with PPI refractory GERD.

Elimination of Dietary Triggers Is Successful in Treating Symptoms of Gastroesophageal Reflux Disease.

BACKGROUND: The relationship between aliments and pathophysiological abnormalities leading to gastroesophageal reflux disease (GERD) symptoms elicitation is unclear. Nevertheless, patients often report symptoms after ingestion of specific foods. AIMS: To identify in primary care setting the presence of foods able to trigger GERD symptoms, and evaluate whether a consequent specific food elimination diet may result in clinical improvement. METHODS: Diagnosis of GERD and quantification of reflux symptoms were done according to GERD-Q questionnaire (positive when > 8). During clinical data collection, patients were asked to report aliments associated with their symptoms. Also, a precompiled list of additional foods was administered to them. Then, patients were requested to eliminate the specific foods identified, and to come back for follow-up visit after 2 weeks when GERD-Q questionnaire and clinical data collection were repeated. RESULTS: One-hundred GERD (mean GERD-Q score 11.6) patients (54 females, mean age 48.7 years) were enrolled. Eighty-five patients reported at least one triggering food, mostly spicy foods (62%), chocolate (55%), pizza (55%), tomato (52%), and fried foods (52%). At follow-up visit, the diagnosis of GERD was confirmed in only 55 patients, and the mean GERD-Q score decreased to 8.9. Heartburn reporting decreased from 93 to 44% of patients, while regurgitation decreased from 72 to 28%. About half of the patients agreed to continue with only dietary recommendations. CONCLUSIONS: Most patients with GERD can identify at least one food triggering their symptoms. An approach based on abstention from identified food may be effective in the short term.

Paroxysmal head drops with ataxia-like symptoms presenting as Sandifer syndrome in a 3-year old girl.

We present a case of Sandifer syndrome in a 3-year-old girl who initially presented with a history of recurrent paroxysmal head drops associated with ataxia-like symptoms and recurrent falls sustaining a clavicular fracture on one occasion. She was referred to and seen by the paediatric neurologist. Physical examination, electroencephalogram, MRI brain, electromyograph single fibre study and blood tests were all normal. With the history of hiccups and choking-like episodes she was referred to the speech and language therapist (SALT). SALT assessment did not reveal indications of swallowing impairment or possible aspiration. A barium swallow later showed small amount of reflux into the distal oesophagus. This prompted a trial of lansoprazole and she was referral to the gastroenterologists. Endoscopy and oesophageal manometry were essentially normal. However, the pH impedance study revealed severe gastro-oesophageal reflux disease. She continued with lansoprazole and dairy-free diet and her symptoms resolved.

Ninety-Six Hour Wireless Esophageal pH Study in Patients with GERD Shows that Restrictive Diet Reduces Esophageal Acid Exposure.

BACKGROUND: Prolonged (96 h) pH monitoring may explore the effect of diet on pH and symptoms in patients with GERD. AIMS: To assess the usefulness of a 96 h esophageal pH study in patients with GER symptoms under different diets (pro- and anti-GER). METHODS: Prospective study of 66 patients with GERD undergoing wireless 96 h pH monitoring. Two-day periods, one on liberal (pro-reflux) and another on restricted (anti-reflux) diet assessed esophageal acid exposure and symptoms. The primary end point was normalization of acid exposure time while on restricted diet. Secondary end point was a > 50% reduction in symptoms with restricted diet. RESULTS: Normal (pH time < 4 of < 6%) was found in 34 patients (51.5%) while on the initial 48 h (liberal) diet [median % time < 4: 3.2 (95% CI, 1.9, 4.0)] and remained normal while on restricted diet [median % time < 4: 2.6 (95% CI, 0.8, 3.4)]. Abnormal acid exposure (% pH time < 4: > 6%) was found in 32 patients (48.5%) while on initial 48 h liberal diet [median % time < 4: 10.5, (95% CI 8.9, 12.6)], and decreased significantly with restricted diet [median % time < 4: 4.5 (95% CI 3.1, 7.3)] (p = 0.001), and normalized with anti-GERD diet in 21 patients (65.6%). Only 11/66 patients were candidates for proton pump inhibitor (PPI) use; 34 had either normal pH studies or normalized them with restricted diet (n = 21). Symptoms did not improve with restricted diet. CONCLUSIONS: The 96-h esophageal pH study tests for GERD under pro- and anti-GER diets and allows minimization of PPI therapy to only 16.6% of patients.

Through Thick and Thin: The In Vitro Effects of Thickeners on Infant Feed Viscosity.

BACKGROUND: Gastroesophageal reflux disease (GERD) is a common problem in neonates, and current modalities for thickening human milk produce inconsistent outcomes. The objective of this in vitro study is to measure the viscosity effect of different thickening strategies. METHODS: We thickened donor human milk (DHM) and formula using various thickeners: starch-based thickeners (SBT; Thick It, rice cereal), and gum-based thickeners (GBT; xanthan gum: Simply Thick, Thicken Up Clear; carob gum: GelMix). We also assessed formula with added starches marketed for reflux, including Similac Spit Up (SSU) and Enfamil AR (EAR). The viscosity of each sample was measured over time using a rotary viscometer. Additional variables, including acidity, temperature, and the addition of human milk fortifier, were tested. RESULTS: Formula can be effectively thickened with all tested thickeners, but the viscosities of thickened formula increase over time. On the other hand, DHM does not effectively thicken with SBT. Autoclaving DHM inactivates digestive enzymes, thus allowing SBT to successfully thicken autoclaved DHM. GBT effectively thickened both DHM and formula but reached higher viscosities than intended based on manufacturer recommendations. Adding acid to xanthan-gum thickened DHM resulted in phase separation and formation of solid precipitant. CONCLUSIONS: Current thickening strategies of preterm infant feeding produces highly variable results in final feed viscosity. The unpredictable properties of gum-based thickeners raise questions about their safety profile. Objective measures of liquid viscosity and careful consideration of acidity and time are recommended for adequate comparisons of thickening regimens. Human milk continues to be the most challenging feed type to thicken.

Popular Remedies for Esophageal Symptoms: a Critical Appraisal.

PURPOSE OF REVIEW: Popular remedies are of ongoing interest to patients experiencing common esophageal symptoms, particularly as typical pharmacologic interventions have been subject to increased scrutiny. Herein we summarize the available data regarding potential risks and benefits of several such remedies. RECENT FINDINGS: With emphasis on reflux and non-cardiac chest pain, research is ongoing into the clinical utility and diverse physiologic mechanisms underlying a variety of complementary and alternative modalities, including dietary manipulation, apple cider vinegar, melatonin, acupuncture, and various herbal products (rikkunshito, STW 5, slippery elm, licorice, and peppermint oil, among others). A substantial gap persists between anecdotal and empirical understandings of the majority of non-pharmacologic remedies for esophageal symptoms. This landscape of popular treatments nevertheless raises several interesting mechanistic hypotheses and compelling opportunities for future research.

Symptoms and dietary practices of irritable bowel syndrome patients compared to controls: results of a USA national survey.

BACKGROUND: Little is known regarding the dietary behaviors and epidemiology of irritable bowel syndrome (IBS) patients in the USA. METHODS: This was an IRB-approved cross-sectional survey conducted via a secured online server (SurveyMonkey®). A representative sample of the US population was queried regarding demographics, gastrointestinal (GI) symptoms, treatments and dietary practices. Of 1718 respondents, 161 reported IBS. These were compared to 1116 subjects reporting no GI diagnosis (controls). RESULTS: Overall, 9% reported a diagnosis of IBS. When compared to controls, IBS patients were more likely over 45 years (P<0.001) and female (P<0.001). IBS patients more frequently noted abdominal pain, constipation, diarrhea, gas/bloating and GERD/heartburn (all P<0.001) than controls. Regarding therapeutic measures, IBS patients were more likely to cite food avoidance, over-the-counter remedies, probiotics, consultation with doctor/dietitian, and prescriptions (all P<0.001). However, they were less likely to believe their strategies were effective. While the majority of subjects believed food contributed to their symptoms, those with IBS listed more dietary triggers. IBS patients were more likely to follow a dietary 'plan' with 21% citing lactose-free, 17% gluten-free and 9% low-FODMAP (all P<0.001). Nevertheless, 47% with IBS denied following any dietary plans. A minority, (24%), of IBS patients was aware of the low-FODMAP diet. CONCLUSIONS: In this US survey, IBS was reported by 9% of the population, most often females over 45 years. IBS patients were more likely to implement therapeutic strategies and cite food triggers, yet few were aware of the low-FODMAP diet. Outreach programs could improve awareness of this substantiated intervention.

Effect of high-fat, standard, and functional food meals on esophageal and gastric pH in patients with gastroesophageal reflux disease and healthy subjects.

OBJECTIVES: To investigate the effects of different test meals on esophageal and intragastric pH in patients with gastroesophageal reflux disease (GERD) and healthy subjects and to demonstrate the relationship between esophageal acid exposure (EAE) and gastric pH. METHODS: We enrolled patients with reflux esophagitis (RE; n = 15), nonerosive reflux disease (NERD; n = 12) and healthy subjects (n = 10). Four pH electrodes were used to monitor the pH of the distal esophagus, upper border of the lower esophageal sphincter, gastric fundus, and gastric body for 26 hours. Isocaloric and isovolumetric high-fat, standard, and functional meals were supplied randomly to the participants. The EAE and gastric acidity of each meal in fasting and postprandial states were compared. RESULTS: High-fat meals significantly increased postprandial EAE in patients with RE and NERD. EAE was higher after a high-fat meal than after a standard or functional food meals at the fourth hour postprandially in patients with RE (P < 0.05). Patients with NERD reported fewer symptoms after a functional food meal than after high-fat and standard meals (0 [interquartile range {IQR} 0-1] vs 1 [IQR 0-2] vs 3 [IQR 1-4], P = 0.014). Compared with high-fat and standard meals, functional food meal significantly decreased gastric acidity in patients with RE. EAE was significantly related to gastric acidity in patients with RE. CONCLUSIONS: High-fat meals increased EAE in patients with RE and NERD. Functional food could serve as adjuvant therapy in GERD patients. EAE was related to gastric acidity in RE patients.

Refractory GERD, beyond proton pump inhibitors.

Pharmacologic therapy, surgery, minimally invasive therapies, and alternative therapies are different options available for the management of refractory GERD. The choice may depend on the cause of refractoriness. Increased gastric acid suppression therapy might be useful in the rare patients with persistent elevated esophageal acid exposure on proton pump inhibitors (PPI). Potassium-competitive acid blockers (P-CAB) might induce a more important acid inhibition than PPI. Baclofen might act as a reflux inhibitor and demonstrates a significant efficacy in rumination syndrome. The role of topical antacid-alginate in refractory GERD might be limited. Surgery might be a valid option in case of persistent pathological acid esophageal exposure despite PPI. Further evaluation of minimally invasive procedures is necessary. Finally diet, diaphragmatic breathing and transcutaneous electrical acustimulation might be of interest in patients with esophageal hypersensivity or functional symptoms.

Fiber-enriched diet helps to control symptoms and improves esophageal motility in patients with non-erosive gastroesophageal reflux disease.

AIM: To investigate the effect of dietary fiber on symptoms and esophageal function testing parameters in non-erosive gastroesophageal reflux disease (GERD) (NERD) patients. METHODS: Thirty-six NERD patients with low (< 20 g/d) dietary fiber intake were enrolled in the study. They were examined with the use of symptom questionnaire (GERD-Q), high-resolution esophageal manometry, 24-h esophageal pH-impedance examinations, and food frequency questionnaire before and after 10 d of usual diet supplemented by psyllium 5.0 g TID. Complete data of 30 patients were available to the final analysis. The obtained results were analyzed with the use of non-parametric statistics (Wilcoxon matched pairs test). RESULTS: The number of patients experiencing heartburn was less (93.3% at baseline vs 40% at the end of the study, P < 0.001) and the GERD-Q score decreased (mean ± SD: 10.9 ± 1.7 vs 6.0 ± 2.3, P < 0.001) after the treatment period. Minimal resting lower esophageal sphincter (LES) pressure increased from 5.41 ± 10.1 to 11.3 ± 9.4 mmHg (P = 0.023), but no change in residual LES pressure and mean resting pressure was found. Total number of gastroesophageal refluxes (GER) decreased from 67.9 ± 17.7 to 42.4 ± 13.5 (P < 0.001) predominantly by acid and weak acid types of GERs. No significant change in mean esophageal pH and % of time pH < 4 was registered. Maximal reflux time decreased from 10.6 ± 12.0 min to 5.3 ± 3.7 min (P < 0.05). CONCLUSION: Fiber-enriched diet led to a significant increase of minimal lower esophageal sphincter resting pressure, a decrease of number of gastroesophageal refluxes, and a decrease of heartburn frequency per week in NERD.

New food approaches to reduce and/or eliminate increased gastric acidity related to gastroesophageal pathologies.

OBJECTIVE: Gastroesophageal reflux disease is very common in industrialized countries and rapidly and significantly increasing even in developing countries. The approach in this study is one not commonly found to date in the scientific literature. To assess the ability of reduced-carbohydrate diets and foods that are enriched with acid potential of hydrogen (pH; lemon and tomato) to quickly and exponentially reduce symptoms that are related to conditions such as gastritis and gastroesophageal reflux and unrelated to Helicobacter pylori. METHODS: After the administration of an anamnestic test, 130 patients were selected including 73 women and 57 men, 21 to 67 y, and with a gastritis diagnosis for 92 patients (56 women, 36 men) and reflux gastritis for 38 patients (17 women, 21 men). Study participants followed three dietary treatments in succession. Each treatment lasted 2 wk and treatments were separated by 2 wk of washout. The patients followed a diet that consisted primarily of proteins and fats and included the exponential reduction of glycides (simple and complex). In addition, the treatment provided for the daily intake of the juice of two lemons and approximately 100 g of fresh orange tomato without seeds eaten either raw or cooked and peeled. RESULTS: During treatment and at the end of 2 wk of treatment, the patients reported significant improvements including an almost total disappearance of symptoms that were related to the disease in question. CONCLUSIONS: This study shows that a carbohydrate-free diet and/or highly hypoglycidal diet that is enriched with acid pH foods appears to lead to a decrease in the pH of the gastric contents, thus inhibiting the further production of hydrochloric acid with a reduction or disappearance of heartburn symptoms that are typical of gastroesophageal diseases.

Can We Use Diet to Effectively Treat Esophageal Disease? A Review of the Current Literature.

PURPOSE OF REVIEW: Esophageal diseases represent a wide variety of conditions affecting esophageal anatomy, physiology, and motility. Therapy focuses on pharmacotherapy and endoscopic or surgical management. Dietary therapy can be considered in management algorithms for specific esophageal diseases. This review focuses on outlining the literature related to dietary therapy in gastroesophageal reflux disease, eosinophilic esophagitis, Barrett's esophagus, and esophageal adenocarcinoma. RECENT FINDINGS: Currently, data are strongest for dietary manipulation in eosinophilic esophagitis, specifically the six-food elimination diet. Dietary effects on gastroesophageal reflux disease are less clear, though newer research indicates that increased fiber with reduction in simple sugar intake may improve symptoms. In terms of Barrett's esophagus and esophageal adenocarcinoma, antioxidant intake may affect carcinogenesis, though to an unknown degree. Outcomes data regarding dietary manipulation for the management of esophageal diseases is heterogeneous. Given the rising interest in non-pharmacological treatment options for these patients, continued research is warranted.

Dietary carbohydrate intake, insulin resistance and gastro-oesophageal reflux disease: a pilot study in European- and African-American obese women.

BACKGROUND: Although obesity rates are higher in African-American than European-American women, gastro-oesophageal reflux disease (GERD) and its comorbidities are more prevalent in European-American women. A common denominator for increased adiposity, and consequent insulin resistance, is excess dietary macronutrient intake - which may promote greater prevalence and severity of GERD in women. AIM: To investigate whether GERD is more robustly associated with dietary carbohydrate intake, particularly dietary simple carbohydrate intake, and insulin resistance in European-American women. METHODS: About 144 obese women were assessed at baseline and 16 weeks after consuming a high-fat/low-carbohydrate diet. GERD diagnosis and medication usage was confirmed in medical records with symptoms and medications assessed weekly. RESULTS: About 33.3% (N = 33) of European-American and 20.0% (N = 9) of African-American women had GERD at baseline. Total carbohydrate (r = 0.34, P < 0.001), sugars (r = 0.30, P = 0.005), glycaemic load (r = 0.34, P = 0.001) and HOMAIR (r = 0.30, P = 0.004) were associated with GERD, but only in European-American women. In response to high-fat/low-carbohydrate diet, reduced intake of sugars was associated with reduced insulin resistance. By the end of diet week 10, all GERD symptoms and medication usage had resolved in all women. CONCLUSIONS: GERD symptoms and medication usage was more prevalent in European-American women, for whom the relationships between dietary carbohydrate intake, insulin resistance and GERD were most significant. Nevertheless, high-fat/low-carbohydrate diet benefited all women with regard to reducing GERD symptoms and frequency of medication use.

Risk factors for reflux esophagitis and countermeasures-Diet.

Reflux esophagitis is increasing in Japan in association with cultural and societal changes to a more Western lifestyle. The major cause is reflux of gastric contents, consisting mainly of gastric acid, into the esophagus. For prevention, it is necessary to give attention to the contents of meals, as well as food form and eating habits. More specifically, it is important to improve lifestyle habits related to diet, such as refraining from ingesting foods that stimu- late gastric acid secretion or promote relaxation of the lower esophageal sphincter, which delays gastric emptying. Furthermore, consuming large meals quickly, lying down immediately after eating, and eating solids, each of which delays gastric emptying, should be avoided, as well as acidic foods and hot meals.

Effects of esophageal capsaicin instillation on acid induced excitation of secondary peristalsis in humans.

BACKGROUND/AIM: Esophageal instillation of capsaicin or hydrochloric acid enhances secondary peristalsis. Our aim was to investigate whether intra-esophageal capsaicin infusion can influence symptom perception and physiological alteration of secondary peristalsis subsequent to acid infusion. METHODS: Secondary peristalsis was induced by mid-esophagus injections of air in 18 healthy subjects. Two different sessions including esophageal infusion of hydrochloric acid (0.1 N) following pretreatment with saline or capsaicin-containing red pepper sauce were randomly performed at least one week apart. Symptoms of heartburn and secondary peristalsis were determined and compared between each study session. RESULTS: The intensity of heartburn symptom subsequent to acid infusion was significantly reduced after capsaicin infusion as compared with saline infusion (54 ± 3 vs 61 ± 3; P = 0.03). Capsaicin infusion significantly increased the threshold volume of secondary peristalsis to rapid air injections subsequent to esophageal acid infusion (8.0 ± 0.5 mL vs 4.4 ± 0.3 mL; P < 0.0001). The frequency of secondary peristalsis subsequent to acid infusion was significantly decreased after capsaicin infusion as compared to saline infusion (70% [60-82.5%] vs 80% [70-90%]; P = 0.03). Capsaicin infusion significantly decreased the pressure wave amplitude of secondary peristalsis subsequent to acid infusion during rapid air injections (90.6 ± 8.7 mmHg vs 111.1 ± 11.1 mmHg; P = 0.03). CONCLUSIONS: Capsaicin appears to desensitize the esophagus to acid induced excitation of secondary peristalsis in humans, which is probably mediated by rapidly adapting mucosal mechanoreceptors. High capsaicin-containing diet might attenuate normal physiological response to abrupt acid reflux by inhibiting secondary peristalsis.

Dietary Intakes and Nutritional Issues in Neurologically Impaired Children.

Neurologically impaired (NI) children are at increased risk of malnutrition due to several nutritional and non-nutritional factors. Among the nutritional factors, insufficient dietary intake as a consequence of feeding difficulties is one of the main issues. Feeding problems are frequently secondary to oropharyngeal dysphagia, which usually correlates with the severity of motor impairment and presents in around 90% of preschool children with cerebral palsy (CP) during the first year of life. Other nutritional factors are represented by excessive nutrient losses, often subsequent to gastroesophageal reflux and altered energy metabolism. Among the non-nutritional factors, the type and severity of neurological impairment, ambulatory status, the degree of cognitive impairment, and use of entiepileptic medication altogether concur to determination of nutritional status. With the present review, the current literature is discussed and a practical approach for nutritional assessment in NI children is proposed. Early identification and intervention of nutritional issues of NI children with a multidisciplinary approach is crucial to improve the overall health and quality of life of these complex children.

Japanese apricot improves symptoms of gastrointestinal dysmotility associated with gastroesophageal reflux disease.

AIM: To investigate the effects of Japanese apricot (JA) consumption on gastroesophageal reflux disease (GERD)-related symptoms. METHODS: Participants included individuals living in Minabe-cho, a well-known JA-growing region, who received specific medical check-ups by the local community health service in 2010. GERD-related symptoms were examined in 1303 Japanese individuals using a validated questionnaire, the Frequency Scale for Symptoms of GERD (FSSG), which consists of 7 questions associated with acid reflux symptoms and 5 questions asking about gastrointestinal dysmotility symptoms. Each question was answered using a 4-point scale, with higher scores indicating more severe GERD-related symptoms. Subjects were divided into two groups according to their intake of dried and pickled JA: daily intake (≥ 1 JA daily) (392 subjects) and none or occasional intake (< 1 JA daily) (911 subjects). FSSG scores were compared between subjects who consumed JA daily and those who did not. Next, subjects were stratified by age, gender and Helicobacter pylori (H. pylori) status for subanalyses. RESULTS: Those who ate JA daily were significantly older than those who did not (60.6 ± 10.5 years vs 56.0 ± 11.0 years, P < 0.001). Total FSSG scores were significantly lower in subjects with daily JA intake than in those with none or only occasional intake (2.13 ± 3.14 vs 2.70 ± 3.82, P = 0.005). In particular, subjects who consumed JA daily showed significantly improved FSSG dysmotility scores compared with subjects who did not (1.05 ± 1.58 vs 1.46 ± 2.11, P < 0.001). In contrast, the FSSG reflux score did not differ between subjects with and without daily intake of JA (1.08 ± 1.90 vs 1.24 ± 2.11, P = 0.177). Subanalysis indicated that improvement in dysmotility by JA intake was specifically observed in non-elderly (1.24 ± 1.68 vs 1.62 ± 2.22, P = 0.005) and H. pylori-negative subjects (0.99 ± 1.58 vs 1.57 ± 2.06, P < 0.001). GERD patients (total FSSG score ≥ 8) were less frequently observed among subjects with daily intake of JA as compared to those without daily intake of JA (6.1% vs 9.7%, P = 0.040). CONCLUSION: Daily JA intake may improve digestive dysmotility symptoms, resulting in relief of GERD symptoms. The effect is more obvious in non-elderly and H. pylori-negative subjects.