Updates to the modern diagnosis of GERD: Lyon consensus 2.0.

The Lyon Consensus provides conclusive criteria for and against the diagnosis of gastro-oesophageal reflux disease (GERD), and adjunctive metrics that consolidate or refute GERD diagnosis when primary criteria are borderline or inconclusive. An international core and working group was assembled to evaluate research since publication of the original Lyon Consensus, and to vote on statements collaboratively developed to update criteria. The Lyon Consensus 2.0 provides a modern definition of actionable GERD, where evidence from oesophageal testing supports revising, escalating or personalising GERD management for the symptomatic patient. Symptoms that have a high versus low likelihood of relationship to reflux episodes are described. Unproven versus proven GERD define diagnostic strategies and testing options. Patients with no prior GERD evidence (unproven GERD) are studied using prolonged wireless pH monitoring or catheter-based pH or pH-monitoring off antisecretory medication, while patients with conclusive GERD evidence (proven GERD) and persisting symptoms are evaluated using pH-impedance monitoring while on optimised antisecretory therapy. The major changes from the original Lyon Consensus criteria include establishment of Los Angeles grade B oesophagitis as conclusive GERD evidence, description of metrics and thresholds to be used with prolonged wireless pH monitoring, and inclusion of parameters useful in diagnosis of refractory GERD when testing is performed on antisecretory therapy in proven GERD. Criteria that have not performed well in the diagnosis of actionable GERD have been retired. Personalisation of investigation and management to each patient's unique presentation will optimise GERD diagnosis and management.

Risk factors associated with functional esophageal disorders (FED) versus gastroesophageal reflux disease (GERD).

INTRODUCTION: Despite the high prevalence of typical symptoms of gastroesophageal reflux disease (GERD), approximately 30% of patients have functional esophageal disorders (FED) on ambulatory reflux monitoring, which may include reflux hypersensitivity (RH; defined as physiologic acid exposure but temporally correlated symptoms of reflux), or functional heartburn (FH; defined as physiologic acid exposure and negative symptom correlation). There are limited epidemiological data characterizing these conditions. We investigated demographic and socioeconomic factors as well as medical comorbidities which may predispose to FED versus pathologic GERD. METHODS: Adult patients with reflux symptoms for at least 3 months were studied with 24-h pH-impedance testing from 11/2019 to 3/2021. Participants were categorized into pathologic GERD, FH, or RH using pH-impedance data and reported symptom correlation. Demographic data, including age, gender, race/ethnicity, zip code, insurance status, and medical comorbidity data were retrospectively retrieved from the electronic medical record on all participants. RESULTS: 229 patients were included. Non-Hispanic Asian ethnicity (OR 5.65; p = 0.01), underweight BMI (OR 7.33; p = 0.06), chronic pain (OR 2.33; p < 0.01), insomnia (OR 2.83; p = 0.06), and allergic rhinitis (OR 3.90; p < 0.01) were associated with a greater risk for FED. Overweight BMI (OR 0.48; p = 0.03) and alcohol use (OR 0.57; p = 0.06) were associated with a decreased risk for FED. DISCUSSION: This is the first report of a greater risk of FED in patients with underweight BMI, insomnia, chronic pain, allergic rhinitis, or of Asian or Hispanic ethnicities. The weak associations between female gender and anxiety are corroborated in other studies. Our findings enable clinicians to better screen patients with reflux for this disorder.

Value of 96-hour ambulatory esophageal pH monitoring in the assessment of patients with refractory acid reflux symptoms and their response to anti-reflux diet.

Ambulatory esophageal pH monitoring is a diagnostic tool in patients with heartburn and regurgitation. The aim of this study is to evaluate 96-hour esophageal pH monitoring in patients with gastroesophageal reflux disease (GERD), at baseline and under diet that impedes GER. We hypothesized that diet would potentially reduce pathologic acid exposure time (AET). Retrospective series of 88 patients with GERD undergoing wireless 96-hour pH monitoring. Two-day (48 hours) tandem periods, one on liberal, followed by another on restricted diet assessed esophageal AET. Primary end point was >30% reduction in AET while on anti-GER diet. Of the 88 patients, 16 were excluded because of probe migration. Endoscopy and biopsies assessed erosive esophagitis (EE) and Barrett's esophagus (BE), or normal esophagus. Abnormal AET (% pH < 4.0 ≥ 6) further defined nonerosive reflux disease (NERD), whereas normal AET (% pH < 4.0 < 6) with normal endoscopy defined patients as functional heartburn (FH). There were 6 patients with EE (n = 5) and BE (n = 1), 23 with NERD and 43 with FH. Anti-GER diet led to >30% reduction in AET in EE and NERD patients, but not in those with FH. Most patients (n = 43/72; 60%) had FH and could have avoided acid suppression. Furthermore, (14/23; 61%) of patients with NERD completely normalized AET with diet, potentially negating acid suppression. Ninety-six-hour esophageal pH distinguishes GERD patients from those with FH. Fifty percent of EE/BE patients and 61% of those with NERD completely normalize AET with diet. If pathologic AET occurs despite diet, acid suppression is indicated.

Number of reflux episodes on pH-impedance monitoring associates with improved symptom outcome and treatment satisfaction in gastro-oesophageal reflux disease (GERD) patients with regurgitation.

OBJECTIVE: Number of reflux episodes, an adjunctive metric on pH-impedance monitoring, is incompletely studied. We aimed to determine if number of reflux episodes associates with therapeutic outcome in regurgitation predominant gastro-oesophageal reflux disease (GERD). DESIGN: We performed post hoc analysis of postintervention pH-impedance data from adult patients with moderate/severe regurgitation despite QD proton pump inhibitor (PPI), randomised to either two times a day PPI or magnetic sphincter augmentation (MSA) in 2:1 allocation. After 6 and 12 months, symptom response was defined by improvement in Foregut Symptom Questionnaire (FSQ) regurgitation score to none or minimal, ≥50% reduction in GERD health-related quality of life (HRQL) score and satisfaction with therapy. Univariate and multivariate analyses were performed to determine predictors of symptom improvement. RESULTS: Of 152 randomised patients, 123 (age 46.9±1.2 year, 43% female) had complete data. Symptom and satisfaction scores significantly improved after MSA compared with two times a day PPI. Both acid exposure time (13.4%±0.7% to 1.3±0.2%, p<0.001) and reflux episodes (86±4 to 48±4, p<0.001) declined with therapy. Reduction to <40 reflux episodes was significantly more frequent in those with symptom response by FSQ regurgitation score, GERD HRQL score and satisfaction with therapy (p≤0.03 for each); <35 episodes performed better on receiver operating characteristic analysis. On multivariate analysis, improvement in regurgitation score remained independently predictive of satisfaction with therapy (p<0.001 for each). In patients crossing over to MSA, >80 episodes pretreatment predicted improvement. CONCLUSIONS: Reduction of reflux episodes on pH-impedance to physiological levels associates with improved outcomes, while pathological levels predict improvement with MSA in regurgitation predominant GERD. TRAIL REGISTRATION NUMBER: ClinicalTrials.gov: NCT02505945.

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.

Does DeMeester score still define GERD?

Gastroesophageal reflux disease (GERD) clinical presentation may encompass a myriad of symptoms that may mimic other esophageal and extra-esophageal diseases. Thus, GERD diagnosis by symptoms only may be inaccurate. Upper digestive endoscopy and barium esophagram may also be misleading. pH monitoring must be added often for a definitive diagnosis. The DeMeester score (DMS) is a composite score of the acid exposure during a prolonged ambulatory pH monitoring that has been used since 1970s to categorize patients as GERD+ or GERD-. We showed in this review that DMS has some limitations and strengths. Although there is not a single instrument to precisely diagnose GERD in all of its variances, pH monitoring analyzed at the light of DMS is still a reliable method for scientific purposes as well as for clinical decision making. There are no data that show that acid exposure time is superior-or for that matter inferior-as compared to DMS.

Whose patient is it? The path to multidisciplinary management of achalasia.

In the past decade, the introduction of high-resolution manometry and the classification of achalasia into subtypes has made possible to accurately diagnose the disease and predict the response to treatment for its different subtypes. However, even to date, in an era of exponential medical progress and increased insight in disease mechanisms, treatment of patients with achalasia is still rather simplistic and mostly confined to mechanical disruption of the lower esophageal sphincter by different means. In addition, there is partial consensus on what is the best form of available treatments for patients with achalasia. Herein, we provide a comprehensive outlook to a general approach to the patient with suspected achalasia by: 1) defining the modern evaluation process; 2) describing the diagnostic value of high-resolution manometry and the Chicago Classification in predicting treatment outcomes and 3) discussing the available treatment options, considering the patient conditions, alternatives available to both the surgeon and the gastroenterologist, and the burden to the health care system. It is our hope that such discussion will contribute to value-based management of achalasia through promoting a leaner clinical flow of patients at all points of care.

Use of Esophageal pH Monitoring to Minimize Proton-Pump Inhibitor Utilization in Patients with Gastroesophageal Reflux Symptoms.

BACKGROUND: Due to concerns about long-term PPI use in patients with acid reflux, we aimed at minimizing PPI use, either by avoiding initiating therapy, downscaling to other therapies, or introducing endoscopic or surgical options. AIMS: To examine the role of esophageal ambulatory pHmetry in minimizing PPI use in patients with heartburn and acid regurgitation. METHODS: Retrospective cohort analysis of patients with reflux symptoms, who underwent endoscopy, manometry, and ambulatory pHmetry to define the need for PPI. Patients were classified as: (1) never users; (2) partial responders to PPI; (3) users with complete response to PPI. Patients were then managed as: (1) PPI non-users; (2) PPI-initiated, and (3) PPI-continued. RESULTS: Of 286 patients with heartburn and regurgitation, 103 (36%) were found to have normal and 183 (64%) abnormal esophageal acid exposure (AET). In the normal AET group, 44/103 had not been treated and were not initiated on PPI. Of the 59 who had previously received PPI, 52 stopped and 7 continued PPI. Hence, PPI were avoided in 96/103 patients (93%). In the abnormal AET group, 61/183 had not been treated and 38 were initiated on PPI and 23 on other therapies. In the 122 patients previously treated with PPI, 24 were not treated with PPI, but with H2RAs, prokinetics, endoscopic, or surgical therapy. Hence, PPI therapy was avoided in 47/183 patients (26%). CONCLUSIONS: In patients with GER symptoms, esophageal pHmetry may avert PPI use in 50%. In the era of caution regarding PPIs, early testing may provide assurance and justification.

Determinants of reflux-induced chronic cough.

OBJECTIVE: Gastro-oesophageal reflux is considered to be an important contributing factor in chronic unexplained cough. It remains unclear why some reflux episodes in the same patient causes cough while others do not. To understand more about the mechanism by which reflux induces cough, we aimed to identify factors which are important in triggering cough. DESIGN: In this multicentre study, 49 patients with reflux-associated chronic cough were analysed using 24-hour pH-impedance-pressure monitoring. The characteristics of reflux episodes that were followed by cough were compared with reflux episodes not associated with cough. RESULTS: The majority (72.4%) of the reflux episodes were acidic (pH<4). Compared with reflux episodes that were not followed by cough, reflux episodes that were followed by a cough burst were associated with a higher proximal extent (p=0.0001), a higher volume clearance time (p=0.002) and a higher acid burden in the preceding 15 min window (p=0.019) and higher reflux burden in the preceding 30 min window (p=0.044). No significant difference was found between the two groups when looking at the nadir pH, the pH drop, the acid clearance time or the percentage of reflux episodes which were acidic. CONCLUSIONS: The presence of a larger volume of refluxate and oesophageal exposure to reflux for a longer period of time seems to play an important role in inducing cough, while the acidity of the refluxate seems to be less relevant. This helps explain the observation that most patients with chronic cough tend not to benefit from acid inhibitory treatment.

The role of impaired esophageal and gastric motility in end-stage lung diseases and after lung transplantation.

Today, many questions persist regarding the causal relationship of gastroesophageal reflux disease (GERD) to promote aspiration and its potential to induce both pulmonary and allograft failure. Current hypotheses, which have identified GERD as a nonimmune risk factor in inducing pulmonary and allograft failure, center on the role of GERD-induced aspiration of gastroduodenal contents. Risk factors of GERD, such as impaired esophageal and gastric motility, may indirectly play a role in the aspiration process. In fact, although impaired esophageal and gastric motility is not independently a cause of lung deterioration or allograft failure, they may cause and or exacerbate GERD. This report seeks to review present research on impaired esophageal and gastric motility in end-stage lung disease to characterize prevalence, etiology, pathophysiology, and current treatment options within this special patient population.

The Transdiaphragmatic Pressure Gradient and the Lower Esophageal Sphincter in the Pathophysiology of Gastroesophageal Reflux Disease: an Analysis of 500 Esophageal Function Tests.

BACKGROUND: Gastroesophageal reflux disease (GERD) pathophysiology is multifactorial. Greater importance has been attributed to a defective lower esophageal sphincter (LES) in comparison to an altered transdiaphragmatic pressure gradient (TPG). This study aims to evaluate the role of the TPG and LES disfunction in GERD pathogenesis. METHODS: Five hundred consecutive esophageal function tests from patients with clinically suspected GERD were reviewed. Patients were classified according to the pH monitoring in GERD positive or GERD negative. Abdominal pressure, thoracic pressure, TPG (abdominal-thoracic pressures), LES resting pressure (mid-respiratory, expiratory, and EGJ-CI), and LES retention pressure (LES resting pressure-TPG) were determined. RESULTS: GERD was present in 296 (59%) individuals. GERD-positive patients were mostly males. LES resting pressure (by all parameters) and thoracic pressure were not different between groups. Abdominal pressure and TPG were higher in GERD-positive patients. LES retention pressure (by all parameters) was lower in GERD-positive patients. DeMeester score had a positive correlation with LES resting pressure, TPG, and LES retention pressure (by all parameters) but not with abdominal pressure and thoracic pressure. CONCLUSIONS: LES valvular competency as measured by absolute resting pressure was not reliable to predict GERD; however, it was associated with GERD severity. Relative LES pressure (LES retention pressure) predicted GERD presence and severity, but no parameter showed superiority. TPG plays an important role in the pathophysiology of GERD since it is related to GERD presence and severity; still TPG is altered mostly based on a higher abdominal pressure.

Diagnostic Criteria for Gastro-esophageal Reflux Following Sleeve Gastrectomy.

BACKGROUND: Gastro-esophageal reflux disease (GERD) post-sleeve gastrectomy (SG) is a controversial issue and diagnostic dilemma. Strong heterogeneity exists in the assessment of reflux post-SG, and better diagnostic tools are needed to characterize symptomatic reflux. We aimed to determine the discriminant factors of symptomatic reflux and establish diagnostic thresholds for GERD following SG. MATERIALS AND METHODS: Patients post-SG were categorized into asymptomatic and symptomatic cohorts and completed validated symptom questionnaires. All patients underwent stationary esophageal manometry and 24-h ambulatory pH monitoring. Univariate and multivariate analyses were conducted to determine the strongest discriminant factors for GERD. RESULTS: Baseline characteristics of the asymptomatic cohort (n = 48) and symptomatic cohort (n = 76) were comparable. The median post-operative duration was 7.3 (14.1) vs 7.5 (10.7) months (p = 0.825). The symptomatic cohort was more female predominant (90.8 vs 72.9%, p = 0.008). Reflux scores were significantly higher in the symptomatic group (36.0 vs 10.5, p = 0.003). Stationary manometry parameters were similar, including hiatus hernia prevalence and impaired esophageal motility. The symptomatic cohort had significantly higher total acid exposure, especially while supine (11.3% vs 0.6%, p < 0.001). Univariate and multivariate regressions delineated reflux score and supine acid exposure as discriminant factors for symptomatic reflux. The thresholds for distinguishing symptomatic reflux are as follows: reflux score of 11.5 (sensitivity 84.0%, specificity 68.2%) and supine acid exposure of 2.65% (sensitivity 67.1%, specificity 70.8%). CONCLUSION: A reflux score of 11.5 or more or supine acid exposure of 2.65% or more should be considered diagnostic in defining symptomatic reflux following SG.

Laparoscopic Posterior Partial Fundoplication for Gastroesophageal Reflux Disease.

Gastroesophageal reflux disease (GERD) is a common condition that greatly impacts quality of life. Management options include medical and surgical therapies. Nonoperative management typically relies on longitudinal use of acid-suppressive medications such as proton pump inhibitors, which is associated with a significant financial burden and an increasing number of recognized side effects. The surgical management of GERD is focused on correction of the lower esophageal sphincter dysfunction by means of a fundoplication, thus limiting acid and nonacid gastroesophageal reflux. Multiple techniques have been described, including use of complete (360°) fundoplication or partial fundoplication in either an anterior (180°) or posterior (220-270°) position. Recent studies have shown that the total and the partial fundoplications are similarly effective in controlling GERD. A partial fundoplication may also be advantageous when treating patients with GERD and poor esophageal motility. This article focuses on the posterior partial (modified Toupet) fundoplication, with attention to the key elements of the preoperative workup, appropriate patient selection, and important technical steps that are associated with the best outcomes.

Bariatric Surgery and Gastroesophageal Reflux.

The epidemic of morbid obesity in the United States has reached dramatic proportions. Because of the associated comorbidities and because life style changes and exercise have limited effect, bariatric surgery has been used more often during the last 10 years as it has been shown to be safe and effective in decreasing weight and resolving comorbidities. Recently many studies have focused on a potential complication of bariatric surgery, gastroesophageal reflux disease, mostly because of the increasing use of sleeve gastrectomy. This article reviews the pathophysiology of reflux in morbid obese patients, the proper work-up before a bariatric operation, and the selection of the procedure based on the individual patient's characteristics.

Evaluation of gastroesophageal reflux disease.

Patients with gastroesophageal reflux disease (GERD) may present with a variety of symptoms, including heartburn, regurgitation, dysphagia, chronic cough, laryngitis, or even asthma. Therefore, the clinical presentation of GERD varies among individuals and conversely symptoms not always correspond to the presence of actual reflux. For that reason, the diagnosis poses certain challenges to the physician. To overcome these challenges, a thorough clinical examination followed by objective functional testing could improve diagnostic accuracy. In addition, a proper evaluation of patients with GERD can help in identifying those who will likely benefit the most from an antireflux procedure. The diagnostic work-up of these patients should include: symptomatic evaluation, upper endoscopy, barium swallow, high-resolution manometry, and ambulatory pH monitoring. Once a proper diagnosis of GERD is achieved, antireflux surgery is an excellent option for patients with partial control of symptoms with medication, for patients who do not want to be on long-term medical treatment (compliance/cost), or when complications of medical treatment occur.

Indications and interpretation of esophageal function testing.

Esophageal symptoms are common, and can arise from mucosal, motor, functional, and neoplastic processes, among others. Judicious use of diagnostic testing can help define the etiology of symptoms and can direct management. Endoscopy, esophageal high-resolution manometry (HRM), ambulatory pH or pH-impedance manometry, and barium radiography are commonly used for esophageal function testing; functional lumen imaging probe is an emerging option. Recent consensus guidelines have provided direction in using test findings toward defining mechanisms of esophageal symptoms. The Chicago Classification describes hierarchical steps in diagnosing esophageal motility disorders. The Lyon Consensus characterizes conclusive evidence on esophageal testing for a diagnosis of gastroesophageal reflux disease (GERD), and establishes a motor classification of GERD. Taking these recent advances into consideration, our discussion focuses primarily on the indications, technique, equipment, and interpretation of esophageal HRM and ambulatory reflux monitoring in the evaluation of esophageal symptoms, and describes indications for alternative esophageal tests.

Laparoscopic Antireflux Surgery: Importance of Patient's Selection and Preoperative Workup.

BACKGROUND: Laparoscopic antireflux surgery (LARS) is an excellent option for patients with symptoms refractory to medical treatment, for patients who have complications secondary to the use of proton pump inhibitors, and for those who do not want to take medications for a long period of time. HYPOTHESIS: We hypothesized that (1) LARS has excellent outcomes if a complete preoperative workup and proper patient selection are performed and (2) recurrent symptoms often are not due to failure of the fundoplication to control the pathologic reflux. PATIENTS AND METHODS: Every patient referred for antireflux surgery underwent a detailed symptomatic evaluation, barium swallow, esophagogastroduodenoscopy (EGD), high-resolution manometry (HRM), and pH monitoring. A fundoplication was performed in all of them. Data were analyzed to determine outcomes across 8 years. RESULTS: From 2008 to 2016, 176 patients with gastroesophageal reflux disease (GERD) underwent LARS. One hundred and thirty-four patients (76.1%) had a total fundoplication, 31 (17.6%) had an anterior partial fundoplication, and 11 (6.3%) had a posterior partial fundoplication. Thirty-nine patients (22.2%) referred persistent or recurrent symptoms after the procedure and underwent EGD, HRM, and pH monitoring. Abnormal reflux was documented in 5 patients (2.8%). Among these failures, 3 patients had a body mass index (BMI) ≥30 and 2 had ≥35. CONCLUSIONS: The results of this study showed that (1) laparoscopic fundoplication is an effective procedure for GERD; (2) patient's BMI can affect the outcome of a fundoplication; and (3) pH monitoring is important to establish if recurrent symptoms are secondary to failure of the operation.

Gastroesophageal reflux disease and morbid obesity: To sleeve or not to sleeve?

Laparoscopic sleeve gastrectomy (LSG) has reached wide popularity during the last 15 years, due to the limited morbidity and mortality rates, and the very good weight loss results and effects on comorbid conditions. However, there are concerns regarding the effects of LSG on gastroesophageal reflux disease (GERD). The interpretation of the current evidence is challenged by the fact that the LSG technique is not standardized, and most studies investigate the presence of GERD by assessing symptoms and the use of acid reducing medications only. A few studies objectively investigated gastroesophageal function and the reflux profile by esophageal manometry and 24-h pH monitoring, reporting postoperative normalization of esophageal acid exposure in up to 85% of patients with preoperative GERD, and occurrence of de novo GERD in about 5% of cases. There is increasing evidence showing the key role of the surgical technique on the incidence of postoperative GERD. Main technical issues are a relative narrowing of the mid portion of the gastric sleeve, a redundant upper part of the sleeve (both depending on the angle under which the sleeve is stapled), and the presence of a hiatal hernia. Concomitant hiatal hernia repair is recommended. To date, either medical therapy with proton pump inhibitors or conversion of LSG to laparoscopic Roux-en-Y gastric bypass are the available options for the management of GERD after LSG. Recently, new minimally invasive approaches have been proposed in patients with GERD and hypotensive LES: the LINX® Reflux Management System procedure and the Stretta® procedure. Large studies are needed to assess the safety and long-term efficacy of these new approaches. In conclusion, the recent publication of pH monitoring data and the new insights in the association between sleeve morphology and GERD control have led to a wider acceptance of LSG as bariatric procedure also in obese patients with GERD, as recently stated in the 5th International Consensus Conference on sleeve gastrectomy.

Inhaled Beta Agonist Bronchodilator Does Not Affect Trans-diaphragmatic Pressure Gradient but Decreases Lower Esophageal Sphincter Retention Pressure in Patients with Chronic Obstructive Pulmonary Disease (COPD) and Gastroesophageal Reflux Disease (GERD).

BACKGROUND: Chronic obstructive pulmonary disease (COPD) patients have a high incidence of gastroesophageal reflux disease (GERD) whose pathophysiology seems to be linked to an increased trans-diaphragmatic pressure gradient and not to a defective esophagogastric barrier. Inhaled beta agonist bronchodilators are a common therapy used by patients with COPD. This drug knowingly not only leads to a decrease in the lower esophageal sphincter (LES) resting pressure, favoring GERD, but also may improve ventilatory parameters, therefore preventing GERD. AIMS: This study aims to evaluate the effect of inhaled beta agonist bronchodilators on the trans-diaphragmatic pressure gradient and the esophagogastric barrier. METHODS: We studied 21 patients (mean age 67 years, 57 % males) with COPD and GERD. All patients underwent high-resolution manometry and esophageal pH monitoring. Abdominal and thoracic pressure, trans-diaphragmatic pressure gradient (abdominal-thoracic pressure), and the LES retention pressure (LES basal pressure-transdiaphragmatic gradient) were measured before and 5 min after inhaling beta agonist bronchodilators. RESULTS: The administration of inhaled beta agonist bronchodilators leads to the following: (a) a simultaneous increase in abdominal and thoracic pressure not affecting the trans-diaphragmatic pressure gradient and (b) a decrease in the LES resting pressure with a reduction of the LES retention pressure. CONCLUSION: In conclusion, inhaled beta agonist bronchodilators not only increase the thoracic pressure but also lead to an increased abdominal pressure favoring GERD by affecting the esophagogastric barrier.