New Directions in the Management of Dyspepsia and GERD
New Directions in the Management of Dyspepsia and GERD
Washington, DC; Monday, May 21, 2007 -- Gastroesophageal reflux disease (GERD) and dyspepsia received considerable focus during Digestive Disease Week (DDW) 2007. This report explores some of the more key issues relevant to these clinically important conditions, as presented during this year's meeting, with a view toward the broader context.
The prevalence of GERD is increasing among both children and adults, and it is truly becoming a global disease. A recent consensus group reviewed the literature on natural history and concluded that there was little progression in disease severity over a 20-year timeframe, but did recognize that there were limited data on natural history in the literature.
In this context, Hansen and colleagues presented data on the long-term course of reflux symptoms. This study evaluated a large cohort of patients as part of a controlled trial on Helicobacter pylori eradication being conducted in Denmark. At baseline, patients filled out a validated scale for reflux symptoms (Gastrointestinal Symptom Rating Scale) and patients were then reevaluated after 5 years. At the 5-year follow-up, 5592 subjects were available for evaluation. The incidence of the typical reflux syndrome was 2.2%/year. Healthcare utilization was significantly higher in patients with reflux symptoms vs in those without these symptoms. At baseline, 22% of subjects reported reflux symptoms. At the 5-year follow-up, symptoms were resolved in 43% of cases (10% of these patients had received proton-pump inhibitor [PPI] therapy). This finding suggests that the majority of patients remained symptomatic at 5 years.
There has been a decline in the prevalence of esophageal strictures noted in hospitals; indeed, gastroenterologists have reported a decline in the number of patients needing dilation of esophageal strictures.This decline in the prevalence of GERD-related strictures has been correlated with the availability of PPIs in the United States. A population-based study presented during this year's meeting provided further confirmation of this observation, showing a decline in the rate of new stricture dilation as well as a decline in the need for recurrent dilation since 1992.
It has been suggested that the incidence of colorectal neoplasia is higher in patients with Barrett's esophagus, and potential mechanisms have been proposed to explain this observation. However, this association is controversial, with some studies having found no increase in the incidence of colorectal neoplasia in patients with Barrett's esophagus. Cook and colleagues studied the natural history of Barrett's esophagus and the risk for extraesophageal cancer incidence in a cohort of 597 patients with Barrett's esophagus recruited at a hospital in the United Kingdom. After exclusions, a group of 431 patients had a diagnosis of specialized intestinal metaplasia and 71 had a diagnosis of columnar-lined esophagus. All-cause mortality was higher in patients with Barrett's esophagus (standardized mortality ratio: 1.21 [95% confidence interval, 1.06-1.37]), even when esophageal cancer was excluded from the analysis. No significant increase in the risk for colorectal cancers, cardiovascular disease, or circulatory disorders was noted in patients with Barrett's esophagus. There was no increase in the incidence of colorectal cancer seen in patients with Barrett's esophagus. Thus, these findings show no evidence for increased risks for other forms of cancer in Barrett's esophagus patients, as has been proposed.f
Dyspepsia is a syndrome defined by a constellation of symptoms and signs. Unfortunately, the actual term and its consequences are poorly understood by patients and physicians alike, and indeed the Rome II criteria for functional dyspepsia were very restrictive. In 2006, the deliberations of the Rome III committee were published and the definition of dyspepsia was again refined. Functional dyspepsia is now defined as the presence of symptoms thought to originate in the gastroduodenal region in the absence of any organic, systemic, or metabolic disease that is likely to explain these symptoms. However, the committee recommended that particularly for experimental purposes, the term "functional dyspepsia" should preferably be replaced by more distinctively defined disorders: (1) meal-induced dyspeptic symptoms (postprandial distress syndrome), and (2) epigastric pain syndrome. Patients with symptoms of postprandial fullness, early satiety, or epigastric pain/burning are referred to as having dyspepsia. The pathogenesis of dyspepsia remains poorly understood, and data presented at DDW 2007 offered insight into the new Rome III definition and the pathogenesis of this disorder.
Two studies presented during DDW 2007 addressed the new Rome III criteria, which propose that postprandial distress syndrome and epigastric pain syndrome be recognized as symptom subgroups of functional dyspepsia, and their possible utility in research and practice. In a retrospective analysis of symptoms and pathophysiologic abnormalities, Kindt and colleagues reported that the epigastric pain syndrome was present in 53% of dyspeptic patients and postprandial distress syndrome in 84% of patients, with an overlap in 47%. Impaired accommodation was more prevalent among patients with the postprandial distress syndrome (39%) than among patients with the epigastric pain syndrome (5%). Hypersensitivity to gastric distention was more prevalent (38%) among patients with both epigastric pain syndrome and postprandial distress syndrome compared with patients who had epigastric pain syndrome or postprandial distress syndrome alone (21%), but these differences were small. In another study presented at this year's meeting, the Rome III criteria were evaluated in a cohort of community-based individuals who had been studied previously in the Leeds dyspepsia trial. Patient symptoms were reevaluated in light of the new Rome III criteria to determine the categories into which subjects would now be classified and to determine whether a clear separation of syndromes would be manifest. Of the 1550 individuals who reported symptoms consistent with the new dyspepsia definition, 781 (50%) were classifiable into both symptom subgroups. Both of these studies demonstrate the limitations of our current classification systems for dyspepsia. The association between pathophysiologic abnormalities and symptom clusters remains weak, and the syndromes that have been defined thus far have been limited by overlap. This makes these syndromes difficult to identify in clinical practice and impossible for patients to decipher.
Additional reported data described pathophysiologic mechanisms that may play a role in dyspepsia. In a study addressing the question of whether duodenal mucosal eosinophils and mast cells may be biomarkers for functional dyspepsia, the authors studied a random sample of the Swedish population who had undergone upper endoscopy and routine biopsy, including duodenal biopsy. The duodenal biopsies showed that eosinophil counts in the proximal duodenum (bulb and second portion) were significantly higher in subjects with functional dyspepsia compared with in healthy controls (bulb: 33 vs 18 eosinophils per high-power-field; second portion of duodenum: 35 vs 19 eosinophils per high-power-field). Duodenal eosinophilia was not related to irritable bowel syndrome. Eosinophilia in the gastrointestinal tract may be related to food sensitivity, and these findings raise interesting questions about the potential cause of dyspeptic symptoms in these patients. In another study, a wireless pH probe placed in the duodenum demonstrated increased duodenal acid delivery in dyspeptic patients. This is not a new finding, in that previous studies have suggested that duodenal acid exposure may be increased in patients with functional dyspepsia. This technique involving a radiotelemetry pH capsule offers a new method for the evaluation of acid exposure in the duodenum without the inconvenience of a transnasal pH probe needing to be placed in the duodenum.
The prevalence of GERD is increasing among both children and adults, and it is truly becoming a global disease. A recent consensus group reviewed the literature on natural history and concluded that there was little progression in disease severity over a 20-year timeframe, but did recognize that there were limited data on natural history in the literature.
In this context, Hansen and colleagues presented data on the long-term course of reflux symptoms. This study evaluated a large cohort of patients as part of a controlled trial on Helicobacter pylori eradication being conducted in Denmark. At baseline, patients filled out a validated scale for reflux symptoms (Gastrointestinal Symptom Rating Scale) and patients were then reevaluated after 5 years. At the 5-year follow-up, 5592 subjects were available for evaluation. The incidence of the typical reflux syndrome was 2.2%/year. Healthcare utilization was significantly higher in patients with reflux symptoms vs in those without these symptoms. At baseline, 22% of subjects reported reflux symptoms. At the 5-year follow-up, symptoms were resolved in 43% of cases (10% of these patients had received proton-pump inhibitor [PPI] therapy). This finding suggests that the majority of patients remained symptomatic at 5 years.
There has been a decline in the prevalence of esophageal strictures noted in hospitals; indeed, gastroenterologists have reported a decline in the number of patients needing dilation of esophageal strictures.This decline in the prevalence of GERD-related strictures has been correlated with the availability of PPIs in the United States. A population-based study presented during this year's meeting provided further confirmation of this observation, showing a decline in the rate of new stricture dilation as well as a decline in the need for recurrent dilation since 1992.
It has been suggested that the incidence of colorectal neoplasia is higher in patients with Barrett's esophagus, and potential mechanisms have been proposed to explain this observation. However, this association is controversial, with some studies having found no increase in the incidence of colorectal neoplasia in patients with Barrett's esophagus. Cook and colleagues studied the natural history of Barrett's esophagus and the risk for extraesophageal cancer incidence in a cohort of 597 patients with Barrett's esophagus recruited at a hospital in the United Kingdom. After exclusions, a group of 431 patients had a diagnosis of specialized intestinal metaplasia and 71 had a diagnosis of columnar-lined esophagus. All-cause mortality was higher in patients with Barrett's esophagus (standardized mortality ratio: 1.21 [95% confidence interval, 1.06-1.37]), even when esophageal cancer was excluded from the analysis. No significant increase in the risk for colorectal cancers, cardiovascular disease, or circulatory disorders was noted in patients with Barrett's esophagus. There was no increase in the incidence of colorectal cancer seen in patients with Barrett's esophagus. Thus, these findings show no evidence for increased risks for other forms of cancer in Barrett's esophagus patients, as has been proposed.
Washington, DC; Monday, May 21, 2007 -- Gastroesophageal reflux disease (GERD) and dyspepsia received considerable focus during Digestive Disease Week (DDW) 2007. This report explores some of the more key issues relevant to these clinically important conditions, as presented during this year's meeting, with a view toward the broader context.
The prevalence of GERD is increasing among both children and adults, and it is truly becoming a global disease. A recent consensus group reviewed the literature on natural history and concluded that there was little progression in disease severity over a 20-year timeframe, but did recognize that there were limited data on natural history in the literature.
In this context, Hansen and colleagues presented data on the long-term course of reflux symptoms. This study evaluated a large cohort of patients as part of a controlled trial on Helicobacter pylori eradication being conducted in Denmark. At baseline, patients filled out a validated scale for reflux symptoms (Gastrointestinal Symptom Rating Scale) and patients were then reevaluated after 5 years. At the 5-year follow-up, 5592 subjects were available for evaluation. The incidence of the typical reflux syndrome was 2.2%/year. Healthcare utilization was significantly higher in patients with reflux symptoms vs in those without these symptoms. At baseline, 22% of subjects reported reflux symptoms. At the 5-year follow-up, symptoms were resolved in 43% of cases (10% of these patients had received proton-pump inhibitor [PPI] therapy). This finding suggests that the majority of patients remained symptomatic at 5 years.
There has been a decline in the prevalence of esophageal strictures noted in hospitals; indeed, gastroenterologists have reported a decline in the number of patients needing dilation of esophageal strictures.This decline in the prevalence of GERD-related strictures has been correlated with the availability of PPIs in the United States. A population-based study presented during this year's meeting provided further confirmation of this observation, showing a decline in the rate of new stricture dilation as well as a decline in the need for recurrent dilation since 1992.
It has been suggested that the incidence of colorectal neoplasia is higher in patients with Barrett's esophagus, and potential mechanisms have been proposed to explain this observation. However, this association is controversial, with some studies having found no increase in the incidence of colorectal neoplasia in patients with Barrett's esophagus. Cook and colleagues studied the natural history of Barrett's esophagus and the risk for extraesophageal cancer incidence in a cohort of 597 patients with Barrett's esophagus recruited at a hospital in the United Kingdom. After exclusions, a group of 431 patients had a diagnosis of specialized intestinal metaplasia and 71 had a diagnosis of columnar-lined esophagus. All-cause mortality was higher in patients with Barrett's esophagus (standardized mortality ratio: 1.21 [95% confidence interval, 1.06-1.37]), even when esophageal cancer was excluded from the analysis. No significant increase in the risk for colorectal cancers, cardiovascular disease, or circulatory disorders was noted in patients with Barrett's esophagus. There was no increase in the incidence of colorectal cancer seen in patients with Barrett's esophagus. Thus, these findings show no evidence for increased risks for other forms of cancer in Barrett's esophagus patients, as has been proposed.f
Dyspepsia: Does Anyone Know What It Is?
Dyspepsia is a syndrome defined by a constellation of symptoms and signs. Unfortunately, the actual term and its consequences are poorly understood by patients and physicians alike, and indeed the Rome II criteria for functional dyspepsia were very restrictive. In 2006, the deliberations of the Rome III committee were published and the definition of dyspepsia was again refined. Functional dyspepsia is now defined as the presence of symptoms thought to originate in the gastroduodenal region in the absence of any organic, systemic, or metabolic disease that is likely to explain these symptoms. However, the committee recommended that particularly for experimental purposes, the term "functional dyspepsia" should preferably be replaced by more distinctively defined disorders: (1) meal-induced dyspeptic symptoms (postprandial distress syndrome), and (2) epigastric pain syndrome. Patients with symptoms of postprandial fullness, early satiety, or epigastric pain/burning are referred to as having dyspepsia. The pathogenesis of dyspepsia remains poorly understood, and data presented at DDW 2007 offered insight into the new Rome III definition and the pathogenesis of this disorder.
Two studies presented during DDW 2007 addressed the new Rome III criteria, which propose that postprandial distress syndrome and epigastric pain syndrome be recognized as symptom subgroups of functional dyspepsia, and their possible utility in research and practice. In a retrospective analysis of symptoms and pathophysiologic abnormalities, Kindt and colleagues reported that the epigastric pain syndrome was present in 53% of dyspeptic patients and postprandial distress syndrome in 84% of patients, with an overlap in 47%. Impaired accommodation was more prevalent among patients with the postprandial distress syndrome (39%) than among patients with the epigastric pain syndrome (5%). Hypersensitivity to gastric distention was more prevalent (38%) among patients with both epigastric pain syndrome and postprandial distress syndrome compared with patients who had epigastric pain syndrome or postprandial distress syndrome alone (21%), but these differences were small. In another study presented at this year's meeting, the Rome III criteria were evaluated in a cohort of community-based individuals who had been studied previously in the Leeds dyspepsia trial. Patient symptoms were reevaluated in light of the new Rome III criteria to determine the categories into which subjects would now be classified and to determine whether a clear separation of syndromes would be manifest. Of the 1550 individuals who reported symptoms consistent with the new dyspepsia definition, 781 (50%) were classifiable into both symptom subgroups. Both of these studies demonstrate the limitations of our current classification systems for dyspepsia. The association between pathophysiologic abnormalities and symptom clusters remains weak, and the syndromes that have been defined thus far have been limited by overlap. This makes these syndromes difficult to identify in clinical practice and impossible for patients to decipher.
Additional reported data described pathophysiologic mechanisms that may play a role in dyspepsia. In a study addressing the question of whether duodenal mucosal eosinophils and mast cells may be biomarkers for functional dyspepsia, the authors studied a random sample of the Swedish population who had undergone upper endoscopy and routine biopsy, including duodenal biopsy. The duodenal biopsies showed that eosinophil counts in the proximal duodenum (bulb and second portion) were significantly higher in subjects with functional dyspepsia compared with in healthy controls (bulb: 33 vs 18 eosinophils per high-power-field; second portion of duodenum: 35 vs 19 eosinophils per high-power-field). Duodenal eosinophilia was not related to irritable bowel syndrome. Eosinophilia in the gastrointestinal tract may be related to food sensitivity, and these findings raise interesting questions about the potential cause of dyspeptic symptoms in these patients. In another study, a wireless pH probe placed in the duodenum demonstrated increased duodenal acid delivery in dyspeptic patients. This is not a new finding, in that previous studies have suggested that duodenal acid exposure may be increased in patients with functional dyspepsia. This technique involving a radiotelemetry pH capsule offers a new method for the evaluation of acid exposure in the duodenum without the inconvenience of a transnasal pH probe needing to be placed in the duodenum.
Reflux Disease: Insights Into the Natural History of GERD
The prevalence of GERD is increasing among both children and adults, and it is truly becoming a global disease. A recent consensus group reviewed the literature on natural history and concluded that there was little progression in disease severity over a 20-year timeframe, but did recognize that there were limited data on natural history in the literature.
In this context, Hansen and colleagues presented data on the long-term course of reflux symptoms. This study evaluated a large cohort of patients as part of a controlled trial on Helicobacter pylori eradication being conducted in Denmark. At baseline, patients filled out a validated scale for reflux symptoms (Gastrointestinal Symptom Rating Scale) and patients were then reevaluated after 5 years. At the 5-year follow-up, 5592 subjects were available for evaluation. The incidence of the typical reflux syndrome was 2.2%/year. Healthcare utilization was significantly higher in patients with reflux symptoms vs in those without these symptoms. At baseline, 22% of subjects reported reflux symptoms. At the 5-year follow-up, symptoms were resolved in 43% of cases (10% of these patients had received proton-pump inhibitor [PPI] therapy). This finding suggests that the majority of patients remained symptomatic at 5 years.
There has been a decline in the prevalence of esophageal strictures noted in hospitals; indeed, gastroenterologists have reported a decline in the number of patients needing dilation of esophageal strictures.This decline in the prevalence of GERD-related strictures has been correlated with the availability of PPIs in the United States. A population-based study presented during this year's meeting provided further confirmation of this observation, showing a decline in the rate of new stricture dilation as well as a decline in the need for recurrent dilation since 1992.
It has been suggested that the incidence of colorectal neoplasia is higher in patients with Barrett's esophagus, and potential mechanisms have been proposed to explain this observation. However, this association is controversial, with some studies having found no increase in the incidence of colorectal neoplasia in patients with Barrett's esophagus. Cook and colleagues studied the natural history of Barrett's esophagus and the risk for extraesophageal cancer incidence in a cohort of 597 patients with Barrett's esophagus recruited at a hospital in the United Kingdom. After exclusions, a group of 431 patients had a diagnosis of specialized intestinal metaplasia and 71 had a diagnosis of columnar-lined esophagus. All-cause mortality was higher in patients with Barrett's esophagus (standardized mortality ratio: 1.21 [95% confidence interval, 1.06-1.37]), even when esophageal cancer was excluded from the analysis. No significant increase in the risk for colorectal cancers, cardiovascular disease, or circulatory disorders was noted in patients with Barrett's esophagus. There was no increase in the incidence of colorectal cancer seen in patients with Barrett's esophagus. Thus, these findings show no evidence for increased risks for other forms of cancer in Barrett's esophagus patients, as has been proposed.
