GERD assessment including pH metry predicts a high response rate to PPI standard therapy

BMC Gastroenterology

Peter Malfertheiner⁴  Jochen Weigt⁴  Helmut Neumann¹  Klaus Mönkemüller²  Ulrich Peitz³  Arne Kandulski⁴ 

[1] Department of Medicine 1, University of Erlangen-Nuremberg, Ulmenweg 18, 91054, Erlangen, Germany;Department of Internal Medicine, Gastroenterology, Marienhospital Bottrop, Josef-Albers-Str. 70, 46236, Bottrop, Germany;Department of Internal Medicine II and Gastroenterology, Loerstraße 23, 48143, Münster, Germany;Department of Gastroenterology, Hepatology and Infectious Diseases, Otto-von-Guericke University Magdeburg, Leipziger Str. 44, 39120, Magdeburg, Germany

关键词: Therapy;    Diagnosis;    ph metry;    Treatment;    Esomeprazole;    PPI;    NERD;    GERD;   

Others  :  858226
DOI  :  10.1186/1471-230X-13-12

 received in 2012-09-24, accepted in 2013-01-09,  发布年份 2013

【 摘 要 】

Background

Inadequate response to proton pump inhibitor (PPI) therapy in patients with gastroesophageal reflux disease (GERD) is reported in up to 40%. Patients with non erosive reflux disease (NERD) have lower response rates compared to patients with erosive reflux disease (ERD); pH metry contributes to GERD diagnosis and is critical for proper diagnosis of NERD.

Aim of the study was to assess the need for doubling esomeprazole standard dose (40 mg) for 4 weeks in PPI naive patients with typical reflux symptoms and diagnosis of GERD based on endoscopy and 48 hours, wireless pH metry.

Methods

All patients underwent upper GI endoscopy. Symptoms were recorded with a structured questionnaire (RDQ) and acid exposure was determined by 48 hours, wireless pH monitoring (BRAVO). In case of abnormal acid exposure, patients received a short term treatment with esomeprazole 40 mg q.d. for 4 weeks. If symptoms persisted, patients underwent a second pH metry on PPI and the dose was increased to 40 mg b.i.d.

Results

31 consecutive patients with typical reflux symptoms underwent 48 hours pH monitoring. 22 patients (71%) had abnormal acid exposure, 9 patients had normal pH metry (29%). Of the 9 patients with normal pH metry, 2 were found with erosive esophagitis and 7 without endoscopic abnormalities.

24 patients with documented GERD received esomeprazole treatment. 21 patients achieved complete symptom resolution with 40 mg q.d. after 4 weeks (88%). Only 2 patients required doubling the dose of esomeprazole for complete symptom resolution, 1 patient remained with symptoms.

Conclusions

Patients with typical reflux symptoms and abnormal acid exposure have a high response rate to standard dose esomeprazole regardless of whether they have ERD or NERD.

【 授权许可】

   
2013 Kandulski et al.; licensee BioMed Central Ltd.

【 图 表 】

【 参考文献 】

• [1]Vakil N, van Zanten SV, Kahrilas P, Dent J, Jones R: The Montreal definition and classification of gastroesophageal reflux disease: a global evidence-based consensus. Am J Gastroenterol 2006, 101:1900-1920.
• [2]Dent J, Vakil N, Jones R, Bytzer P, Schoning U, Halling K, Junghard O, Lind T: Accuracy of the diagnosis of GORD by questionnaire, physicians and a trial of proton pump inhibitor treatment: the Diamond Study. Gut 2010, 59:714-721.
• [3]Kahrilas PJ, Smout AJ: Esophageal disorders. Am J Gastroenterol 2010, 105:747-756.
• [4]Lundell LR, Dent J, Bennett JR, Blum AL, Armstrong D, Galmiche JP, Johnson F, Hongo M, Richter JE, Spechler SJ, et al.: Endoscopic assessment of oesophagitis: clinical and functional correlates and further validation of the Los Angeles classification. Gut 1999, 45:172-180.
• [5]Lichtenstein DR, Cash BD, Davila R, Baron TH, Adler DG, Anderson MA, Dominitz JA, Gan SI, Harrison ME III, Ikenberry SO, et al.: Role of endoscopy in the management of GERD. Gastrointest Endosc 2007, 66:219-224.
• [6]Pandolfino JE, Richter JE, Ours T, Guardino JM, Chapman J, Kahrilas PJ: Ambulatory esophageal pH monitoring using a wireless system. Am J Gastroenterol 2003, 98:740-749.
• [7]Sifrim D, Castell D, Dent J, Kahrilas PJ: Gastro-oesophageal reflux monitoring: review and consensus report on detection and definitions of acid, non-acid, and gas reflux. Gut 2004, 53:1024-1031.
• [8]Sweis R, Fox M, Anggiansah R, Anggiansah A, Basavaraju K, Canavan R, Wong T: Patient acceptance and clinical impact of Bravo monitoring in patients with previous failed catheter-based studies. Aliment Pharmacol Ther 2009, 29:669-676.
• [9]Sweis R, Fox M, Anggiansah A, Wong T: Prolonged, wireless pH-studies have a high diagnostic yield in patients with reflux symptoms and negative 24-h catheter-based pH-studies. Neurogastroenterol Motil 2011, 23:419-426.
• [10]Galmiche JP, Clouse RE, Balint A, Cook IJ, Kahrilas PJ, Paterson WG, Smout AJ: Functional esophageal disorders. Gastroenterology 2006, 130:1459-1465.
• [11]Johnsson F, Hatlebakk JG, Klintenberg AC, Roman J: Symptom-relieving effect of esomeprazole 40 mg daily in patients with heartburn. Scand J Gastroenterol 2003, 38:347-353.
• [12]Gardner JD, Sloan S, Miner PB, Robinson M: Determination of the reduction in gastric acidity necessary to prevent pathological oesophageal reflux in patients with gastro-oesophageal reflux disease treated with a proton pump inhibitor. Aliment Pharmacol Ther 2003, 17:955-964.
• [13]Khan M, Santana J, Donnellan C, Preston C, Moayyedi P: Medical treatments in the short term management of reflux oesophagitis. Cochrane Database Syst Rev 2007, CD003244.
• [14]van Pinxteren B, Sigterman KE, Bonis P, Lau J, Numans ME: Short-term treatment with proton pump inhibitors, H2-receptor antagonists and prokinetics for gastro-oesophageal reflux disease-like symptoms and endoscopy negative reflux disease. Cochrane Database Syst Rev 2010, CD002095.
• [15]Tack J, Koek G, Demedts I, Sifrim D, Janssens J: Gastroesophageal reflux disease poorly responsive to single-dose proton pump inhibitors in patients without Barrett’s esophagus: acid reflux, bile reflux, or both? Am J Gastroenterol 2004, 99:981-988.
• [16]Dean BB, Gano AD Jr, Knight K, Ofman JJ, Fass R: Effectiveness of proton pump inhibitors in nonerosive reflux disease. Clin Gastroenterol Hepatol 2004, 2:656-664.
• [17]Labenz J, Armstrong D, Lauritsen K, Katelaris P, Schmidt S, Schutze K, Wallner G, Juergens H, Preiksaitis H, Keeling N, et al.: A randomized comparative study of esomeprazole 40 mg versus pantoprazole 40 mg for healing erosive oesophagitis: the EXPO study. Aliment Pharmacol Ther 2005, 21:739-746.
• [18]Nocon M, Kulig M, Leodolter A, Malfertheiner P, Willich SN: Validation of the reflux disease questionnaire for a german population. Eur J Gastroenterol Hepatol 2005, 17:229-233.
• [19]Shaw MJ, Talley NJ, Beebe TJ, Rockwood T, Carlsson R, Adlis S, Fendrick AM, Jones R, Dent J, Bytzer P: Initial validation of a diagnostic questionnaire for gastroesophageal reflux disease. Am J Gastroenterol 2001, 96:52-57.
• [20]Weijenborg PW, Cremonini F, Smout AJ, Bredenoord AJ: PPI therapy is equally effective in well-defined non-erosive reflux disease and in reflux esophagitis: a meta-analysis. Neurogastroenterol Motil 2012, 24:747-757.
• [21]Fass R, Shapiro M, Dekel R, Sewell J: Systematic review: proton-pump inhibitor failure in gastro-oesophageal reflux disease–where next? Aliment Pharmacol Ther 2005, 22:79-94.
• [22]Malfertheiner P, Lind T, Willich S, Vieth M, Jaspersen D, Labenz J, Meyer-Sabellek W, Junghard O, Stolte M: Prognostic influence of Barrett’s oesophagus and Helicobacter pylori infection on healing of erosive gastro-oesophageal reflux disease (GORD) and symptom resolution in non-erosive GORD: report from the ProGORD study. Gut 2005, 54:746-751.
• [23]Kahrilas PJ: Review article: is stringent control of gastric pH useful and practical in GERD? Aliment Pharmacol Ther 2004, 20(Suppl 5):89-94.
• [24]Sifrim D, Holloway R, Silny J, Xin Z, Tack J, Lerut A, Janssens J: Acid, nonacid, and gas reflux in patients with gastroesophageal reflux disease during ambulatory 24-hour pH-impedance recordings. Gastroenterology 2001, 120:1588-1598.
• [25]Sifrim D, Mittal R, Fass R, Smout A, Castell D, Tack J, Gregersen H: Review article: acidity and volume of the refluxate in the genesis of gastro-oesophageal reflux disease symptoms. Aliment Pharmacol Ther 2007, 25:1003-1017.
• [26]Ward EM, Devault KR, Bouras EP, Stark ME, Wolfsen HC, Davis DM, Nedrow SI, Achem SR: Successful oesophageal pH monitoring with a catheter-free system. Aliment Pharmacol Ther 2004, 19:449-454.
• [27]Neumann H, Monkemuller K, Kandulski A, Malfertheiner P: Dyspepsia and IBS symptoms in patients with NERD. ERD and Barrett’s esophagus. Dig Dis 2008, 26:243-247.
• [28]Savarino V, Savarino E, Parodi A, Dulbecco P: Functional heartburn and non-erosive reflux disease. Dig Dis 2007, 25:172-174.
• [29]Tutuian R, Vela MF, Hill EG, Mainie I, Agrawal A, Castell DO: Characteristics of symptomatic reflux episodes on Acid suppressive therapy. Am J Gastroenterol 2008, 103:1090-1096.
• [30]Gasiorowska A, Navarro-Rodriguez T, Wendel C, Krupinski E, Perry ZH, Koenig K, Moty B, Powers J, Fass R: Comparison of the degree of duodenogastroesophageal reflux and acid reflux between patients who failed to respond and those who were successfully treated with a proton pump inhibitor once daily. Am J Gastroenterol 2009, 104:2005-2013.
• [31]Kandulski A, Wex T, Monkemuller K, Kuester D, Fry LC, Roessner A, Malfertheiner P: Proteinase-activated receptor-2 in the pathogenesis of gastroesophageal reflux disease. Am J Gastroenterol 2010, 105:1934-1943.
• [32]Kandulski A, Malfertheiner P: Gastroesophageal reflux disease–from reflux episodes to mucosal inflammation. Nat Rev Gastroenterol Hepatol 2012, 9:15-22.
• [33]Bautista J, Fullerton H, Briseno M, Cui H, Fass R: The effect of an empirical trial of high-dose lansoprazole on symptom response of patients with non-cardiac chest pain–a randomized, double-blind, placebo-controlled, crossover trial. Aliment Pharmacol Ther 2004, 19:1123-1130.
• [34]Dickman R, Emmons S, Cui H, Sewell J, Hernandez D, Esquivel RF, Fass R: The effect of a therapeutic trial of high-dose rabeprazole on symptom response of patients with non-cardiac chest pain: a randomized, double-blind, placebo-controlled, crossover trial. Aliment Pharmacol Ther 2005, 22:547-555.