Background—Endoscopic oesophageal changes are diagnostically helpful and identify patients exposed to the risk of dis- ease chronicity. However, there is a seri- ous lack of agreement about how to describe and classify the appearance of reflux oesophagitis Aims—To examine the reliability of crite- ria that describe the circumferential ex- tent of mucosal breaks and to evaluate the functional and clinical correlates of pa- tients with reflux disease whose oesoph- agitis was graded according to the Los Angeles system. Methods—Forty six endoscopists from diVerent countries used a detailed work- sheet to evaluate endoscopic video record- ings from 22 patients with the full range of severity of reflux oesophagitis. In separate studies, Los Angeles system gradings were correlated with 24 hour oesophageal pH monitoring (178 patients), and with clini- cal trials of omeprazole treatment (277 patients). Results—Evaluation of circumferential extent of oesophagitis by the criterion of whether mucosal breaks extended be- tween the tops of mucosal folds, gave acceptable agreement (mean Œ value 0.4) among observers. This approach is used in the Los Angeles system. An alternative approach of grouping the circumferential extent of mucosal breaks as occupying 0-25%, 26-50%, 51-75%, 76-99%, or 100% of the oesophageal circumference, gave unacceptably high interobserver variation (mean Œ values 0-0.15) for all but the low- est category of extent (mean Œ value 0.4). Severity of oesophageal acid exposure was significantly (p<0.001) related to the se- verity grade of oesophagitis. Preteatment oesophagitis grades A-C were related to heartburn severity (p<0.01), outcomes of omeprazole (10 mg daily) treatment (p<0.01),and the risk for symptom relapse oV therapy over six months (p<0.05). Conclusions—Results add further support to previous studies for the clinical utility of the Los Angeles system for endoscopic grading of oesophagitis. (Gut 1999;45:172-180)

https://gut.bmj.com/content/gutjnl/45/2/172.full.pdf

Endoscopic assessment of oesophagitis: clinical and functional correlates and further validation of the Los Angeles classification.

Clinical Trials: A Practical Approach

https://www.gastroscan.ru/literature/pdf/acg02-gerd-treatment.pdf

Updated guidelines for the diagnosis and treatment of gastroesophageal reflux disease

This report summarises conclusions from an evidence-based workshop which evaluated major clinical strategies for the management of the full spectrum of gastro-oesophageal reflux disease, with an emphasis on medical management.

The disease was defined by the presence of oesophageal mucosal breaks or by the occurrence of reflux induced symptoms severe enough to impair quality of life. Endoscopy negative patients were recognised as the most common subgroup; most of these patients can be diagnosed by a well structured symptom analysis. There is a consistent hierarchy of effectiveness of available initial and long term therapies that applies for all patient subgroups. Lifestyle measures were judged to be of such low efficacy that they were rejected as a primary therapy for all patient subgroups. Proton pump inhibitor therapy was considered the initial medical treatment of choice because of its clearly superior efficacy which results in the most prompt achievement of desirable outcomes at the lowest overall medical cost. It was acknowledged that most of patients require long term management and that any maintenance therapy should be chosen by step down to the regimen that is still effective, but least costly. Endoscopic monitoring of routine long term therapy was considered inappropriate, on the basis that control of symptoms is an acceptably reliable indicator of healing in patients with oesophagitis.

Laparoscopic antireflux surgery was recognised as a significant therapeutic advance, the results of which, however, depend substantially on the experience of the surgeon. There are currently no published direct comparisons of cost and efficacy outcomes of optimal medical and surgical therapies for reflux disease. To a significant degree, the choice between medical and surgical therapy should depend on informed patient preference.

Substantial advances have occurred recently in the understanding and treatment of reflux disease. By contrast, there has been relatively little research into the best …

https://gut.bmj.com/content/gutjnl/44/suppl_2/S1.full.pdf

An evidence-based appraisal of reflux disease management — the Genval Workshop Report

A 53-year-old man, who is otherwise healthy and has a 20-year history of occasional heartburn, reports having had worsening heartburn for the past 12 months, with daily symptoms that disturb his sleep. He reports having had no dysphagia, gastrointestinal bleeding, or weight loss and in fact has recently gained 20 lb (9 kg). What would you advise regarding his evaluation and treatment?

https://www.nejm.org/doi/pdf/10.1056/NEJMcp0804684

Gastroesophageal Reflux Disease

The aim of this study was to compare recurrence rates of reflux oesophagitis (after endoscopic healing with omeprazole) over a 12 month period of randomised, double blind, maintenance treatment with either daily omeprazole (20 mg every morning; n = 53), weekend omeprazole (20 mg on three consecutive days a week, n = 55) or daily ranitidine (150 mg twice daily, n = 51). Patients were assessed for relapse by endoscopy (with gastric biopsy) at six and 12 months, or in the event of symptomatic recurrence, and serum gastrin was monitored. At 12 months, the estimated proportions of patients in remission (actuarial life table method) were 89% when receiving daily omeprazole compared with 32% when receiving weekend omeprazole (difference 57%, p < 0.001, 95% confidence intervals: 42% to 71%) and 25% when receiving daily ranitidine (difference 64%, p < 0.001, 95% confidence intervals: 50% to 78%). Median gastrin concentrations increased slightly during the healing phase, but remained within the normal range and did not change during maintenance treatment. No significant pathological findings were noted, and no adverse events were attributable to the study treatments. In conclusion, for patients who respond favourably to acute treatment with omeprazole 20 mg every morning, the drug is a safe and highly effective maintenance treatment for preventing relapse of reflux oesophagitis and its associated symptoms over 12 months. By contrast, weekend omeprazole and daily ranitidine were ineffective.

https://gut.bmj.com/content/gutjnl/35/5/590.full.pdf

D.J. Hetzel

Papers

Omeprazole v ranitidine for prevention of relapse in reflux oesophagitis. A controlled double blind trial of their efficacy and safety.