Increased Prandial Air Swallowing and Postprandial Gas-Liquid Reflux Among Patients Refractory to Proton Pump Inhibitor Therapy

Bravi, I.; Woodland, Philip; Gill, Ravinder S.; Al-Zinaty, M; Bredenoord, Albert J.; Sifrim, Daniel

doi:10.1016/j.cgh.2012.12.041

Cited by 23 publications

(37 citation statements)

References 23 publications

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“…Other studies suggested that reflux perception was enhanced by the presence of gas in the refluxate in patients with non-erosive reflux disease (10) and in patients with poor response to acid suppressive therapy (11). This is consistent with the observation of Bravi et al that air swallowing might be an important factor in PPI non-response (12). Among patients with typical GERD symptoms and abnormal esophageal acid exposure off PPI, the frequency of air swallowing was greater in the 26 patients who failed to respond to PPI therapy compared to 18 patients who responded.…”

Section: Introductionsupporting

confidence: 93%

Majority of symptoms in esophageal reflux PPI non‐responders are not related to reflux

Roman

Keefer

Imam

et al. 2015

Neurogastroenterology Motil

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Background Genesis of persistent gastro-esophageal reflux symptoms despite proton pump inhibitor (PPI) therapy is not fully understood. We aimed at determining reflux patterns on 24-h pH-impedance monitoring performed on PPI and correlating impedance patterns and symptom occurrence in PPI non-responders. Methods 78 PPI non-responder patients underwent 24-h pH-impedance monitoring on PPI. Reflux impedance characterization included gastric and supragastric belches and proximal extent of reflux. Symptoms were considered associated with reflux if occurring within 5 min after a reflux event. Patients were classified into 3 groups: persistent acid reflux (acid esophageal exposure (AET) >5% of time), reflux sensitivity (AET<5%, symptom index (SI) ≥50%), and functional symptoms (AET<5%, SI<50%). Dominant impedance pattern was determined for each patient. Key results 7 patients (9%) had persistent acid reflux, 28 (36%) reflux sensitivity and 43 (55%) functional symptoms. A total of 4,296 reflux events were identified (median per patient 45 (range 4–221)). Although liquid reflux was the most common pattern in all groups, patients with reflux sensitivity and functional symptoms had much more variability in their pattern profile with a large proportion being associated with gastric and supra-gastric belching. Only 417 reflux events (9.7%) were associated with symptoms. Reflux with a supragastric component and proximal extent were more likely to be associated with symptoms. Conclusions & Inferences The impedance reflux profile in PPI non-responders was heterogeneous and the majority of reflux events were not associated with symptoms. Thus, the treatment of PPI non-responders should focus on mechanisms beyond reflux, such as visceral hypersensitivity and hypervigilance.

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Section: Introductionsupporting

confidence: 93%

Majority of symptoms in esophageal reflux PPI non‐responders are not related to reflux

Roman

Keefer

Imam

et al. 2015

Neurogastroenterology Motil

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“…Some patients with gastroesophageal reflux disease have more swallows of air at meal time and also have more reflux episodes that contain gas, a situation that increases the possibility of no response to treatment with proton pump inhibitors (1) .…”

Section: Discussionmentioning

confidence: 99%

“…In recent years, belching as a symptom has received increased attention (1,3,4,7,8,9,10) . The objective of this study was to evaluate the esophageal contraction and transit after wet swallows in patients with troublesome belching.…”

Section: Esophageal Motility In Troublesome Belchingmentioning

confidence: 99%

Esophageal Motility in Troublesome Belching

Silva

Aprile

Dantas

2013

Arq. Gastroenterol.

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-Context -Supragastric belches are the main determinants of troublesome belching symptoms. In supragastric belches, air is rapidly brought into the esophagus and is immediately followed by a rapid expulsion before it has reached the stomach. Objective -To evaluate the esophageal contraction and transit after wet swallows in patients with troublesome belching. Methods -Esophageal contraction and transit were evaluated in 16 patients with troublesome belching and 15 controls. They were measured at 5, 10, 15, and 20 cm from the lower esophageal sphincter (LES) by a solid state manometric and impedance catheter. Each subject swallowed five 5 mL boluses of saline. Results -The amplitude, duration and area under the curve of contractions were similar in patients with troublesome belching and control subjects. The total esophageal bolus transit time was 6.2 (1.8) s in patients with troublesome belching and 6.1 (2.3) s in controls (P = 0.55). The bolus presence time was longer in controls than in patients at 5 cm from the LES [controls: There was no difference in segment transit time. Conclusion -There was no difference in esophageal contractions between patients with troublesome belching and controls. The swallowed bolus went slower into the proximal and middle esophageal body in patients than in control, but cross the distal esophageal body faster in patients than in controls.

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“…Belching does not seem to facilitate acid reflux in healthy subjects . However, the presence of gas in the refluxate enhances reflux perception, is frequently associated with proximal extent of reflux, and occurs more frequently in patients who do not respond to acid‐suppressive treatment …”

Section: Aerophagia Gas Reflux and Supragastric Belching In The Patmentioning

confidence: 99%

Between GERD and NERD: the relevance of weakly acidic reflux

Bortoli

Ottonello

Zerbib³

et al. 2016

Annals of the New York Academy of Sciences

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Nonerosive reflux disease (NERD) is a common condition and the most frequent phenotype of gastroesophageal reflux disease (GERD). NERD is extremely heterogeneous and includes patients with negative endoscopy but abnormal esophageal acid exposure and/or positive reflux-symptom association analysis (hypersensitive esophagus). This segregation is only possible owing to the use of impedance-pH monitoring. Indeed, weakly acidic reflux represents one of the most common causes of refractory symptoms in patients evaluated off antisecretory therapy and, more importantly, during antisecretory drug treatment. Patients with heartburn who do not have any type of reflux underlying their symptoms (functional heartburn) must be excluded from the category of GERD. The drawbacks of impedance-pH are mainly due to the day-to-day variability of the test and the fact that the accuracy of the symptom-reflux correlation scores is often far from perfect. Some histopathological characteristics, such as dilated intercellular spaces, can be helpful in distinguishing patients with NERD through esophageal biopsies. Patients with NERD in whom acid is the main pathogenetic factor respond successfully to proton pump inhibitor therapy, while those with hypersensitive esophagus to weakly acidic reflux could be treated with reflux inhibitors or surgery, although further controlled studies are required.

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Increased Prandial Air Swallowing and Postprandial Gas-Liquid Reflux Among Patients Refractory to Proton Pump Inhibitor Therapy

Cited by 23 publications

References 23 publications

Majority of symptoms in esophageal reflux PPI non‐responders are not related to reflux

Majority of symptoms in esophageal reflux PPI non‐responders are not related to reflux

Esophageal Motility in Troublesome Belching

Between GERD and NERD: the relevance of weakly acidic reflux

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