The prevalence of intestinal dysbiosis in patients referred for antireflux surgery

Abstract

Background Prior to antireflux surgery, most patients with symptoms of gastroesophageal reflux disease (GERD) have been taking long-term proton pump inhibitors (PPIs). PPIs have been shown to cause changes to the intestinal microbiota, such as small intestinal bacterial overgrowth (SIBO), which is characterised by symptoms of gas bloating. Patients undergoing antireflux surgery are not routinely screened for SIBO, yet many patients experience gas-related symptoms postoperatively. Methods Data from consecutive patients (n = 104) referred to a speciality reflux centre were retrospectively assessed. Patients underwent a routine diagnostic workup for GERD including history, endoscopy, oesophageal manometry and 24-h pH-impedance monitoring off PPIs. Intestinal dysbiosis was determined by hydrogen and methane breath testing with a hydrogen-positive result indicative of SIBO and a methane-positive result indicative of intestinal methanogen overgrowth (IMO). Results 60.6% of patients had intestinal dysbiosis (39.4% had SIBO and 35.6% had IMO). Patients with dysbiosis were more likely to report bloating (74.6% vs 48.8%; P = 0.01) and belching (60.3% vs 34.1%; P = 0.01). The oesophageal acid exposure time and number of reflux episodes were similar between dysbiosis and non-dysbiosis groups, but patients with dysbiosis were more likely to have a positive reflux-symptom association (76.2% vs 31.7%; P < 0.001), especially for regurgitation in those with SIBO (P = 0.01). Hydrogen gas production was significantly greater in patients with a positive reflux-symptom association for regurgitation (228.8 ppm vs 129.1 ppm, P = 0.004) and belching (mean AUC 214.8 ppm vs 135.9 ppm, P = 0.02). Conclusions The prevalence of intestinal dysbiosis is high in patients with GERD, and these patients are more likely to report gas-related symptoms prior to antireflux surgery. Independently, SIBO may be a contributory factor to refractory reflux symptoms and gas bloating in antireflux surgery candidates.

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“…12,13 June 2022 PPIs, Antibiotics, and Immunotherapies including conditions such as gastroesophageal reflux disease. 25,26 These underlying gastrointestinal diseases are also often associated with poor prognostic factors, such as smoking, older age, and higher ECOG PS. Coincidingly, it is hypothesized that PPIs could be a multifaceted clinical marker associated with altered ICI efficacy; and with PPIs so often used in patients with cancer (often for long time periods), the association with ICI efficacy could be profound and long lasting.…”

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“…Haworth et al [5] retrospectively evaluated data from patients referred to specialized reflux centers (n = 104) and found a high prevalence of gut flora dysbiosis in GERD patients and a seemingly increased likelihood of positive reflux symptoms, a common indication for anti-reflux surgery. These patients were more likely to report gas-related symptoms prior to anti-reflux surgery, and therefore endogenous bacterial fermentation in the small intestine is presumed to be a contributing factor to refractory reflux symptoms.…”

“…The most common symptom of GERD is a burning sensation behind the sternum (heartburn) or reflux of gastric contents into the upper throat (acid reflux), and recurrent episodes of GERD can affect the quality of life of patients and also increase the economic burden on families and society. The mechanism of GERD is still unclear and its pathogenesis is multifactorial, such as: anti-reflux barriers, esophageal clearance and weakened esophageal mucosal resistance [4], and several recent studies have shown that small intestinal bacterial overgrowth is significantly higher in populations where GERD occurs than in normal populations, and Jordan J. Haworth et al [5] showed for the first time that refractory GERD symptoms may be the result of altered gut microbiota result. Currently proton pump inhibitors (PPIs: proton pump inhibitors) are still the drug of choice for the treatment of GERD to induce remission and maintenance therapy; however, some articles have reported that long-term PPI intake is likely to cause several complications such as: osteoporosis, fractures, micronutrient deficiencies, chronic kidney disease, and can even increase the risk of novel coronavirus pneumonia infection, etc.…”

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“…Similarly to LPR, there is no widely accepted gold standard test for SIBO, but hydrogen and methane breath testing is cheap, non-invasive and recommended by societal guidelines. [12] SIBO is predominantly associated with symptoms of irritable bowel syndrome (IBS), but it was recently demonstrated that a large proportion of patients being worked up for gastroesophageal reflux disease (GERD) have SIBO. [13] Currently, the association between SIBO and LPR is unknown.…”