MEDLINE Abstracts: Diagnosis of GERD
MEDLINE Abstracts: Diagnosis of GERD
What's new concerning the diagnosis of gastroesophageal reflux disease (GERD)? Find out in this easy-to-navigate collection of recent MEDLINE abstracts compiled by the editors at Medscape Gastroenterology.
Marsh RE, Perdue CL, Awad ZT, et al
World J Gastroenterol. 2003;9:174-178
Aim: With successful surgical treatment of gastroesophageal reflux disease (GERD), there is interest in understanding the anti-reflux barrier and its mechanisms of failure. To date, the potential use of vector volumes to predict the DeMeester score has not been adequately explored.
Methods: 627 patients in the referral database received esophageal manometry and ambulatory 24-hour pH monitoring. Study data included LES resting pressure (LESP), overall LES length (OL) and abdominal length (AL), total vector volume (TVV) and intrabdominal vector volume (IVV).
Results: In cases where LESP, TVV or IVV were all below normal, there was an 81.4 % probability of a positive DeMeester score. In cases where all three were normal, there was an 86.9 % probability that the DeMeester score would be negative. Receiver-operating characteristics (ROC) for LESP, TVV and IVV were nearly identical and indicated no useful cut-off values. Logistic regression demonstrated that LESP and IVV had the strongest association with a positive DeMeester score; however, the regression formula was only 76.1 % accurate.
Conclusion: While the indices based on TVV, IVV and LESP are more sensitive and specific, respectively, than any single measurement, the measurement of vector volumes does not add significantly to the diagnosis of GERD.
Manterola C, Munoz S, Grande L, Bustos L
J Clin Epidemiol. 2002;55:1041-1045
There is a high prevalence of gastroesophageal reflux disease (GERD) in the general population. Prevalence studies are scarce, and there is a lack of valid instruments for measuring them. The aim of this paper is to validate a questionnaire for detecting GERD. A validity study design with pathologic GERD patients and controls was used. A sample of 240 subjects age and sex paired was selected in the ratio of 3:1 (patients to controls). The initial structured questionnaire contained a variety of GERD symptoms. Internal consistency, interobserver reliability, criteria validity using 24-h esophageal pH monitoring, construct validity, and extreme group validation were assessed. Sensitivity, specificity, and predictive values were also obtained in different cutoff points of the definitive scale. A total of 180 confirmed GERD patients and 60 controls were included in the study. Mean age in years was 45 +/- 13, with no statistical difference by gender (67% were female). Internal consistency of 0.75 and interobserver reliability of 0.87 was achieved in building the scale. Extreme group validation was highly significant by assessing the scale score with 24-h esophageal pH monitoring (P <.0001). At cutoff point 3 of the scale and with a correct classification of subjects of 92.4%, sensitivity, specificity, positive, and negative predictive values were 92, 95, 98, and 79%, respectively. The conclusion of this article is that a reliable and valid instrument was built to detect GERD.
Eisendrath P, Tack J, Deviere J
Endoscopy. 2002;34:998-1003
Background and Study Aims: The aim of the present study was to analyze the results of a prospective national survey conducted in Belgium to investigate discrepancies between general practitioners' attitudes and the available guidelines on the management of new patients with symptoms of gastroesophageal reflux disease (GERD).
Methods: A total of 641 general practitioners (GPs) were asked to complete a questionnaire on each consultation by a patient with suspected GERD.
Results: The study population included 2234 patients (mean age +/- SD: 47.37 +/- 16.23 years; 52 % aged 45 or older) consulting for the first time for GERD symptoms, without previous endoscopy. Symptoms were classified as mild, moderate, or severe in 39.5 %, 48.0 %, and 11.3 % respectively, and as typical, atypical, or "alarm" in 87.5 %, 16.8 %, and 10.5 % respectively. Upper gastrointestinal endoscopy was requested by GPs in 24.7 % of patients (553 of 2234; including 186 cases that were not justified according to the guidelines), while it should have been requested in 56.6 % (1266 of 2234) if the GPs had respected the national guidelines. Only 28.4 % of the 1171 patients aged 45 or older and 52.6 % of the 95 patients under 45 presenting with alarm symptoms had an endoscopy requested at the first visit. A stepwise multiple logistic regression analysis showed that anemia and symptom severity were the two main factors prompting the GPs to request endoscopy for these patients.
Conclusions: There are major discrepancies between GP practice and national or international guidelines for GERD diagnosis. GPs clearly underused endoscopy in patients with alarm symptoms of GERD and in older patients with a new onset of GERD symptoms. GPs are more strongly influenced by the severity of symptoms than by the type of symptoms.
Mantynen T, Farkkila M, Kunnamo I, Mecklin JP, Juhola M, Voutilainen M
Am J Gastroenterol. 2002;97:2524-2529
Objectives: Less than half of patients with gastroesophageal reflux disease (GERD) have endoscopic erosive esophagitis (endoscopy positive GERD). Symptomatic GERD and Barrett's esophagus (BE), however, are risk factors for esophageal and gastric cardia adenocarcinomas. The aim of the present study was to examine the prevalence of GERD-related findings on endoscopy according to the volume of referrals to upper GI endoscopy.
Methods: The following data were gathered on all GERD patients who were sent for upper GI endoscopy by general practitioners (GPs) during 1 yr in our hospital referral area of 260,000 inhabitants: the number of referrals to endoscopy in health care units, and the numbers of endoscopy positive GERD, BE, and esophageal neoplasms. Patients with symptoms or signs suggesting acute upper GI bleeding and those attending follow-up endoscopy (e.g., for BE, peptic ulcer, or dysplasia) were excluded, as were patients with previous esophagogastric surgery or Helicobacter pylori eradication therapy.
Results: The study population consisted of 3378 patients, with a mean age of 58.1 yr (95% CI = 57.5-58.6) and a male:female ratio of 1:1.3. Of the 760 patients who underwent endoscopy because of heartburn or regurgitation, 254 (33.4%) had endoscopy positive (erosive) GERD, 11 (1.4%) BE (one with esophageal adenocarcinoma), six (0.8%) esophageal ulcer, and one peptic esophageal stricture (0.1%). Between health care units, the referrals to endoscopy (number of endoscopies/population/yr) varied from 0.6 to 9.2/1000 inhabitants/yr (median 3.3/1000/yr). In health care units with "high" referral volumes (> or = 3.3 referrals/1000/yr, N = 15, 1297 patients) and "low" referral volumes (< 3.3/1000/yr, N = 15, 2081 patients), the numbers of endoscopy positive GERD were 281 (21.7%) versus 308 (14.9%, p < 0.001), esophageal ulcer 13 (1.0%) versus 14 (0.7%, p = 0.3), esophageal stricture five (0.4%) versus seven (0.3%, p = 0.4), Barrett's esophagus eight (0.6%) versus 16 (0.8%, p = 0.6), and esophageal neoplasm two (0.2%) versus six (0.3%, p = 0.2). Five of the neoplasms were squamous cell carcinomas, two were adenocarcinomas, and one was lymphoma. Multivariate analyses showed that independent risk factors for endoscopy positive GERD were male sex (OR = 1.4, 95% CI = 1.2-1.7), GERD symptoms (OR = 3.3, 95% CI = 2.7-4.0), dysphagia (OR = 1.4,95% CI = 1.0-2.1), and living in a high referral area (OR = 1.4, 95% CI = 1.2-1.7). Independent risk factors for BE were male sex (OR = 2.6, 95% CI = 1.1-6.1) and GERD symptoms (OR = 2.9, 95% CI = 1.3-6.6), whereas the only independent risk factor for esophageal neoplasm was dysphagia (OR = 40.0 (95% CI = 7.7-207.5).
Conclusions: There is a wide variation in GPs' referrals for endoscopy. Increasing the referral volume significantly increases the proportion of endoscopy positive GERD cases, but not that of GERD complications such as BE, esophageal ulcer, peptic stricture, or esophageal neoplasms.
Pandak WM, Arezo S, Everett S, et al
J Clin Gastroenterol. 2002;35:307-314
Noncardiac chest pain (NCCP) presents as a frequent diagnostic challenge, with patients tending to use a disproportionate level of health care resources. Gastroesophageal reflux disease (GERD) is the most frequent cause of NCCP.
Goals: To test the efficacy of a potent acid-suppressing agent as a diagnostic test in the evaluation of NCCP and to compare it with three commonly used tests.
Study: Eighteen men and 24 women, aged 22 to 77 years, who presented with recurrent chest pain complaints of a noncardiac etiology, as determined by rest/stress perfusion imaging with technetium Tc99m sestamibi (MIBI), were enrolled in a prospective, double-blinded, placebo-controlled, crossover trial using high-dose omeprazole. Thirty-seven patients completed both arms of the trial. Findings were compared with those of endoscopy, manometry, and ambulatory 24-hour two-channel esophageal pH monitoring. All patients underwent initial diagnostic upper endoscopy, esophageal manometry, and 24-hour pH monitoring. Patients were then randomly assigned to either placebo or omeprazole (40 mg/d orally twice daily) for 14 days, washed out for 21 days, and then crossed over. Patient's symptoms were determined using a Visual Analogue Scale to measure the severity of chest pain before and after each period.
Results: Seventy-one percent of patients in the omeprazole arm reported improved chest pain, whereas only 18% in the placebo arm did. Abnormal results on manometry (20%), 24-hour pH monitoring (42%), or endoscopy with visual evidence of esophagitis (26%) were found less frequently. Combination of the three tests did not significantly increase their usefulness. In NCCP patients with GERD, as defined by positive results on a 24-hour pH test or presence of esophagitis on endoscopy, omeprazole treatment led to a response in 95% of patients, whereas 90% of GERD-positive patients treated with placebo did not respond. Of NCCP patients determined to be GERD negative, 39% responded to omeprazole.
Conclusions: Omeprazole as a first diagnostic tool in the evaluation of MIBI-negative NCCP is sensitive and specific for determining the cause of NCCP. Endoscopy, manometry, and 24-hour pH monitoring were not only less sensitive in diagnosing NCCP, but they were significantly more expensive.
Ofman JJ, Shaw M, Sadik K, et al
Dig Dis Sci. 2002;47:1863-1869
A reliable, accurate noninvasive method for identifying patients with gastroesophageal reflux disease (GERD) in the primary care setting is needed. A population-based case-finding instrument may assist managed care organizations in identifying candidates for disease management or quality improvement programs. Our aim was to develop and validate a GERD case-finding instrument. A 12-item "GERD Screener" was developed based on literature review and expert opinion with questions about heartburn and regurgitation frequency and severity and medication use, as well demographics and exclusion criteria. Categorical and continuous scoring methods with and without medication use were developed a priori. Using a telephone interview in a medical group, we identified and enrolled 100 subjects with a history of GERD-like symptoms and 103 controls. Each subject completed the GERD Screener, a validated gastrointestinal symptom questionnaire, the Digestive Health Symptom Index (DHSI), and was evaluated independently by two gastroenterologists using a structured format. Agreement by the two physicians that symptoms were consistent with GERD and required an intervention was considered the gold standard. In all, 70 subjects were classified as having GERD and 106 as controls using the gold standard (K = 0.73; 95% CI, 0.63-0.82). The scoring method for the screening instrument using a continuous measure of GERD symptoms (frequency and severity) and weighted medication use resulted in an area under ROC of 0.89 (95% CI, 0.84-0.94). Using a cutoff of >9 points, this measure was 83% sensitive and 83% specific. Compared to the gold standard, the DHSI GERD subscale has an area under ROC of 0.89 (95% CI, 0.84-0.94). The GERD Screener was highly correlated with the DHSI GERD subscale, r = 0.78 (95% CI 0.72-0.83; P < 0.0001). In conclusion, the GERD Screener has demonstrated construct, convergent, and predictive validity. It is shorter than existing validated instruments, practical, and easily administered, which may reduce the response and administrative burden. This may serve as a valuable case-finding instrument in primary-care and managed-care organizations wishing to implement programs to improve the quality and efficiency of care.
What's new concerning the diagnosis of gastroesophageal reflux disease (GERD)? Find out in this easy-to-navigate collection of recent MEDLINE abstracts compiled by the editors at Medscape Gastroenterology.
Marsh RE, Perdue CL, Awad ZT, et al
World J Gastroenterol. 2003;9:174-178
Aim: With successful surgical treatment of gastroesophageal reflux disease (GERD), there is interest in understanding the anti-reflux barrier and its mechanisms of failure. To date, the potential use of vector volumes to predict the DeMeester score has not been adequately explored.
Methods: 627 patients in the referral database received esophageal manometry and ambulatory 24-hour pH monitoring. Study data included LES resting pressure (LESP), overall LES length (OL) and abdominal length (AL), total vector volume (TVV) and intrabdominal vector volume (IVV).
Results: In cases where LESP, TVV or IVV were all below normal, there was an 81.4 % probability of a positive DeMeester score. In cases where all three were normal, there was an 86.9 % probability that the DeMeester score would be negative. Receiver-operating characteristics (ROC) for LESP, TVV and IVV were nearly identical and indicated no useful cut-off values. Logistic regression demonstrated that LESP and IVV had the strongest association with a positive DeMeester score; however, the regression formula was only 76.1 % accurate.
Conclusion: While the indices based on TVV, IVV and LESP are more sensitive and specific, respectively, than any single measurement, the measurement of vector volumes does not add significantly to the diagnosis of GERD.
Manterola C, Munoz S, Grande L, Bustos L
J Clin Epidemiol. 2002;55:1041-1045
There is a high prevalence of gastroesophageal reflux disease (GERD) in the general population. Prevalence studies are scarce, and there is a lack of valid instruments for measuring them. The aim of this paper is to validate a questionnaire for detecting GERD. A validity study design with pathologic GERD patients and controls was used. A sample of 240 subjects age and sex paired was selected in the ratio of 3:1 (patients to controls). The initial structured questionnaire contained a variety of GERD symptoms. Internal consistency, interobserver reliability, criteria validity using 24-h esophageal pH monitoring, construct validity, and extreme group validation were assessed. Sensitivity, specificity, and predictive values were also obtained in different cutoff points of the definitive scale. A total of 180 confirmed GERD patients and 60 controls were included in the study. Mean age in years was 45 +/- 13, with no statistical difference by gender (67% were female). Internal consistency of 0.75 and interobserver reliability of 0.87 was achieved in building the scale. Extreme group validation was highly significant by assessing the scale score with 24-h esophageal pH monitoring (P <.0001). At cutoff point 3 of the scale and with a correct classification of subjects of 92.4%, sensitivity, specificity, positive, and negative predictive values were 92, 95, 98, and 79%, respectively. The conclusion of this article is that a reliable and valid instrument was built to detect GERD.
Eisendrath P, Tack J, Deviere J
Endoscopy. 2002;34:998-1003
Background and Study Aims: The aim of the present study was to analyze the results of a prospective national survey conducted in Belgium to investigate discrepancies between general practitioners' attitudes and the available guidelines on the management of new patients with symptoms of gastroesophageal reflux disease (GERD).
Methods: A total of 641 general practitioners (GPs) were asked to complete a questionnaire on each consultation by a patient with suspected GERD.
Results: The study population included 2234 patients (mean age +/- SD: 47.37 +/- 16.23 years; 52 % aged 45 or older) consulting for the first time for GERD symptoms, without previous endoscopy. Symptoms were classified as mild, moderate, or severe in 39.5 %, 48.0 %, and 11.3 % respectively, and as typical, atypical, or "alarm" in 87.5 %, 16.8 %, and 10.5 % respectively. Upper gastrointestinal endoscopy was requested by GPs in 24.7 % of patients (553 of 2234; including 186 cases that were not justified according to the guidelines), while it should have been requested in 56.6 % (1266 of 2234) if the GPs had respected the national guidelines. Only 28.4 % of the 1171 patients aged 45 or older and 52.6 % of the 95 patients under 45 presenting with alarm symptoms had an endoscopy requested at the first visit. A stepwise multiple logistic regression analysis showed that anemia and symptom severity were the two main factors prompting the GPs to request endoscopy for these patients.
Conclusions: There are major discrepancies between GP practice and national or international guidelines for GERD diagnosis. GPs clearly underused endoscopy in patients with alarm symptoms of GERD and in older patients with a new onset of GERD symptoms. GPs are more strongly influenced by the severity of symptoms than by the type of symptoms.
Mantynen T, Farkkila M, Kunnamo I, Mecklin JP, Juhola M, Voutilainen M
Am J Gastroenterol. 2002;97:2524-2529
Objectives: Less than half of patients with gastroesophageal reflux disease (GERD) have endoscopic erosive esophagitis (endoscopy positive GERD). Symptomatic GERD and Barrett's esophagus (BE), however, are risk factors for esophageal and gastric cardia adenocarcinomas. The aim of the present study was to examine the prevalence of GERD-related findings on endoscopy according to the volume of referrals to upper GI endoscopy.
Methods: The following data were gathered on all GERD patients who were sent for upper GI endoscopy by general practitioners (GPs) during 1 yr in our hospital referral area of 260,000 inhabitants: the number of referrals to endoscopy in health care units, and the numbers of endoscopy positive GERD, BE, and esophageal neoplasms. Patients with symptoms or signs suggesting acute upper GI bleeding and those attending follow-up endoscopy (e.g., for BE, peptic ulcer, or dysplasia) were excluded, as were patients with previous esophagogastric surgery or Helicobacter pylori eradication therapy.
Results: The study population consisted of 3378 patients, with a mean age of 58.1 yr (95% CI = 57.5-58.6) and a male:female ratio of 1:1.3. Of the 760 patients who underwent endoscopy because of heartburn or regurgitation, 254 (33.4%) had endoscopy positive (erosive) GERD, 11 (1.4%) BE (one with esophageal adenocarcinoma), six (0.8%) esophageal ulcer, and one peptic esophageal stricture (0.1%). Between health care units, the referrals to endoscopy (number of endoscopies/population/yr) varied from 0.6 to 9.2/1000 inhabitants/yr (median 3.3/1000/yr). In health care units with "high" referral volumes (> or = 3.3 referrals/1000/yr, N = 15, 1297 patients) and "low" referral volumes (< 3.3/1000/yr, N = 15, 2081 patients), the numbers of endoscopy positive GERD were 281 (21.7%) versus 308 (14.9%, p < 0.001), esophageal ulcer 13 (1.0%) versus 14 (0.7%, p = 0.3), esophageal stricture five (0.4%) versus seven (0.3%, p = 0.4), Barrett's esophagus eight (0.6%) versus 16 (0.8%, p = 0.6), and esophageal neoplasm two (0.2%) versus six (0.3%, p = 0.2). Five of the neoplasms were squamous cell carcinomas, two were adenocarcinomas, and one was lymphoma. Multivariate analyses showed that independent risk factors for endoscopy positive GERD were male sex (OR = 1.4, 95% CI = 1.2-1.7), GERD symptoms (OR = 3.3, 95% CI = 2.7-4.0), dysphagia (OR = 1.4,95% CI = 1.0-2.1), and living in a high referral area (OR = 1.4, 95% CI = 1.2-1.7). Independent risk factors for BE were male sex (OR = 2.6, 95% CI = 1.1-6.1) and GERD symptoms (OR = 2.9, 95% CI = 1.3-6.6), whereas the only independent risk factor for esophageal neoplasm was dysphagia (OR = 40.0 (95% CI = 7.7-207.5).
Conclusions: There is a wide variation in GPs' referrals for endoscopy. Increasing the referral volume significantly increases the proportion of endoscopy positive GERD cases, but not that of GERD complications such as BE, esophageal ulcer, peptic stricture, or esophageal neoplasms.
Pandak WM, Arezo S, Everett S, et al
J Clin Gastroenterol. 2002;35:307-314
Noncardiac chest pain (NCCP) presents as a frequent diagnostic challenge, with patients tending to use a disproportionate level of health care resources. Gastroesophageal reflux disease (GERD) is the most frequent cause of NCCP.
Goals: To test the efficacy of a potent acid-suppressing agent as a diagnostic test in the evaluation of NCCP and to compare it with three commonly used tests.
Study: Eighteen men and 24 women, aged 22 to 77 years, who presented with recurrent chest pain complaints of a noncardiac etiology, as determined by rest/stress perfusion imaging with technetium Tc99m sestamibi (MIBI), were enrolled in a prospective, double-blinded, placebo-controlled, crossover trial using high-dose omeprazole. Thirty-seven patients completed both arms of the trial. Findings were compared with those of endoscopy, manometry, and ambulatory 24-hour two-channel esophageal pH monitoring. All patients underwent initial diagnostic upper endoscopy, esophageal manometry, and 24-hour pH monitoring. Patients were then randomly assigned to either placebo or omeprazole (40 mg/d orally twice daily) for 14 days, washed out for 21 days, and then crossed over. Patient's symptoms were determined using a Visual Analogue Scale to measure the severity of chest pain before and after each period.
Results: Seventy-one percent of patients in the omeprazole arm reported improved chest pain, whereas only 18% in the placebo arm did. Abnormal results on manometry (20%), 24-hour pH monitoring (42%), or endoscopy with visual evidence of esophagitis (26%) were found less frequently. Combination of the three tests did not significantly increase their usefulness. In NCCP patients with GERD, as defined by positive results on a 24-hour pH test or presence of esophagitis on endoscopy, omeprazole treatment led to a response in 95% of patients, whereas 90% of GERD-positive patients treated with placebo did not respond. Of NCCP patients determined to be GERD negative, 39% responded to omeprazole.
Conclusions: Omeprazole as a first diagnostic tool in the evaluation of MIBI-negative NCCP is sensitive and specific for determining the cause of NCCP. Endoscopy, manometry, and 24-hour pH monitoring were not only less sensitive in diagnosing NCCP, but they were significantly more expensive.
Ofman JJ, Shaw M, Sadik K, et al
Dig Dis Sci. 2002;47:1863-1869
A reliable, accurate noninvasive method for identifying patients with gastroesophageal reflux disease (GERD) in the primary care setting is needed. A population-based case-finding instrument may assist managed care organizations in identifying candidates for disease management or quality improvement programs. Our aim was to develop and validate a GERD case-finding instrument. A 12-item "GERD Screener" was developed based on literature review and expert opinion with questions about heartburn and regurgitation frequency and severity and medication use, as well demographics and exclusion criteria. Categorical and continuous scoring methods with and without medication use were developed a priori. Using a telephone interview in a medical group, we identified and enrolled 100 subjects with a history of GERD-like symptoms and 103 controls. Each subject completed the GERD Screener, a validated gastrointestinal symptom questionnaire, the Digestive Health Symptom Index (DHSI), and was evaluated independently by two gastroenterologists using a structured format. Agreement by the two physicians that symptoms were consistent with GERD and required an intervention was considered the gold standard. In all, 70 subjects were classified as having GERD and 106 as controls using the gold standard (K = 0.73; 95% CI, 0.63-0.82). The scoring method for the screening instrument using a continuous measure of GERD symptoms (frequency and severity) and weighted medication use resulted in an area under ROC of 0.89 (95% CI, 0.84-0.94). Using a cutoff of >9 points, this measure was 83% sensitive and 83% specific. Compared to the gold standard, the DHSI GERD subscale has an area under ROC of 0.89 (95% CI, 0.84-0.94). The GERD Screener was highly correlated with the DHSI GERD subscale, r = 0.78 (95% CI 0.72-0.83; P < 0.0001). In conclusion, the GERD Screener has demonstrated construct, convergent, and predictive validity. It is shorter than existing validated instruments, practical, and easily administered, which may reduce the response and administrative burden. This may serve as a valuable case-finding instrument in primary-care and managed-care organizations wishing to implement programs to improve the quality and efficiency of care.
Source...