Heartburn during sleep: a clinical marker of gastro-oesophageal reflux disease in morbidly obese patients.
01 Feb 2009-Neurogastroenterology and Motility (Blackwell Publishing Ltd)-Vol. 21, Iss: 2, pp 136-142
TL;DR: Symptomatic reflux during the sleep seems to be a marker of increased heartburn perception in this population of patients with morbid obesity and has high positive predictive value for GORD.
Abstract: Gastro-oesophageal reflux disease (GORD) and morbid obesity are entities with increasing prevalence. New clinical strategies are cornerstones for their management. The aim of this study was to assess the prevalence of heartburn during sleep (HDS) and whether this symptom predicts the presence of objective GORD parameters and increased heartburn perception in morbidly obese patients. Ninety-one consecutive morbidly obese patients underwent clin- ical evaluation, upper gastrointestinal endoscopy and oesophageal pH monitoring. HDS was characterized when patients replied positively to the question, Does heartburn wake you from sleep?. A General Score for Heartburn (GSH) ranging between 0 and 5 was assessed with the question How bad is your heartburn?. HDS was reported by 33 patients (36%). More patients with HDS had abnormal acid contact time or reflux oesophagitis than patients without HDS (94% vs 57%, P < 0.001). HDS had a positive predictive value of 94% (0.95 CI 82-98), sensitivity of 48% (0.95 CI 37-60%) and specificity of 93% (0.95 CI 77-98%) for detection of GORD. A higher proportion of patients with HDS perceived heartburn preceded by acid reflux in diurnal (39% vs 9%; P < 0.001) periods during pH-metry. HDS patients showed higher GSH (2.4 ± 0.5 vs 1.7 ± 0.4; P < 0.0001) compared with patients who denied HDS but reported diurnal heartburn. HDS occurs in a signi- ficant minority of patients with morbid obesity and has high positive predictive value for GORD. Symptomatic reflux during the sleep seems to be a marker of increased heartburn perception in this population.
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TL;DR: X-ray is superior to endoscopy in diagnosing SHH either before or after banded GBP in morbidly obese patients, and in patients treated with this technique, the utilization of X-ray may help in the management of reflux symptoms and frequent vomit.
Abstract: The main clinical consequence of sliding hiatal hernia (SHH) is gastroesophageal reflux disease (GERD). Endoscopy and barium swallow X-ray are commonly used to diagnose SHH. We aimed to assess the clinical utility of endoscopy and X-ray in the diagnosis of SHH in morbidly obese patients before and after gastric bypass (GBP). Ninety-two patients underwent reflux symptoms evaluation, upper gastrointestinal endoscopy, and barium swallow X-ray before and 6 months after banded GBP. The performance of endoscopy in diagnosing SHH was assessed, taking X-ray as reference. Endoscopy and X-ray were tested as predictors of SHH with GERD. SHH was more prevalent when characterized by X-ray than endoscopy either before (33% vs. 17%; P = 0.017) or after GBP (26% vs. 7%; P = 0.001). Endoscopy showed low sensitivity (≤40%) and high specificity (≥94%) in diagnosing SHH. Before GBP, more patients with SHH had GERD compared to patients without SHH using either X-ray (83% vs. 58%; P = 0.016) or endoscopy (94% vs. 61%; P = 0.009). After GBP, only patients with radiologic evidence of SHH showed higher prevalence of GERD compared to patients without SHH (50% vs. 26%; P = 0.037). SHH patients also reported weekly or daily vomit more often than patients without SHH (59% vs. 32%; P = 0.026). In morbidly obese patients, X-ray is superior to endoscopy in diagnosing SHH either before or after banded GBP. In patients treated with this technique, the utilization of X-ray may help in the management of reflux symptoms and frequent vomit.
39 citations
Cites methods from "Heartburn during sleep: a clinical ..."
...In this population, endoscopy has been routinely used either to assess reflux symptoms or as part of the evaluation for bariatric surgery [18–20]....
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TL;DR: A bidirectional relationship between gastroesophageal reflux disease and sleep in which nighttime reflux leads to sleep deprivation and sleep deprivation can exacerbate GERD by enhancing perception of intraesophagal stimuli is demonstrated.
Abstract: Recent studies demonstrate a bidirectional relationship between gastroesophageal reflux disease (GERD) and sleep in which nighttime reflux leads to sleep deprivation and sleep deprivation can exacerbate GERD by enhancing perception of intraesophageal stimuli. Current treatment primarily focuses on reducing nighttime reflux, thus improving sleep quality. Future studies are needed to further explore the relationship between GERD and sleep and the potential of novel therapeutic options to interrupt the vicious cycle between them.
33 citations
Cites background from "Heartburn during sleep: a clinical ..."
...Recently, it was shown that heartburn that awakens patients from sleep during the night is highly predictive of GERD [ 14 ]....
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TL;DR: There is recent good evidence that weight reduction and smoking cessation are beneficial in reducing GORD symptoms and clinical and physiological studies also suggest that some physical measures as well as modification of meal size and timing can also be beneficial.
Abstract: Several lifestyle and dietary factors are commonly cited as risk factors for gastro-oesophageal reflux disease (GORD) and modification of these factors has been advocated as first-line measures for the management of GORD. We performed a systematic review of the literature from 2005 to the present relating to the effect of these factors and their modification on GORD symptoms, physiological parameters of reflux as well as endoscopic appearances. Conflicting results existed for the association between smoking, alcohol and various dietary factors in the development of GORD. These equivocal findings are partly due to methodology problems. There is recent good evidence that weight reduction and smoking cessation are beneficial in reducing GORD symptoms. Clinical and physiological studies also suggest that some physical measures as well as modification of meal size and timing can also be beneficial. However, there is limited evidence for the role of avoiding alcohol and certain dietary ingredients including carbonated drinks, caffeine, fat, spicy foods, chocolate and mint.
33 citations
TL;DR: A bidirectional relationship between gastroesophageal reflux disease and sleep and the potential of novel therapeutic options to interrupt the vicious cycle between GERD and sleep is demonstrated.
Abstract: Recent studies have demonstrated a bidirectional relationship between gastroesophageal reflux disease (GERD) and sleep where night-time reflux leads to sleep deprivation and sleep deprivation per se can exacerbate GERD by enhancing perception of intra-esophageal stimuli. Presently, treatment has primarily focused on reducing night-time reflux and thus improving sleep quality. Future studies are needed to further explore the relationship between GERD and sleep and the potential of novel therapeutic options to interrupt the vicious cycle between GERD and sleep.
32 citations
TL;DR: Treatment of nocturnal GER has been shown to improve both subjective and objective sleep measures, and the therapeutic approach includes lifestyle modifications and medication individualization and optimization with proton-pump inhibitors serving as the mainstay of treatment.
Abstract: Gastroesophageal reflux disease (GERD) is a prevalent, chronic medical condition that affects 13% of the adult population globally at least once a week. Sleep disturbances are frequently encountered in up to 25% of the GERD patients, likely due to nocturnal gastroesophageal reflux (GER). With advance in diagnostic techniques allowing for an improved understanding of involved physiological mechanisms of nocturnal reflux, there is growing evidence of a bidirectional relationship between GERD and sleep disturbances. Furthermore, nocturnal GER is associated with more complicated GERD. Obstructive sleep apnea (OSA) and GERD also have been linked, but to what degree remains controversial. Treatment of nocturnal GER has been shown to improve both subjective and objective sleep measures. The therapeutic approach includes lifestyle modifications and medication individualization and optimization with proton-pump inhibitors serving as the mainstay of treatment. Antireflux surgery and newer endoscopic procedures have been demonstrated to control nocturnal GER.
22 citations
References
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TL;DR: These estimates suggest that the increases in body weight are continuing in men and in children and adolescents while they may be leveling off in women; among women, no overall increases in the prevalence of obesity were observed.
Abstract: ContextThe prevalence of overweight in children and adolescents and obesity in adults in the United States has increased over several decades.ObjectiveTo provide current estimates of the prevalence and trends of overweight in children and adolescents and obesity in adults.Design, Setting, and ParticipantsAnalysis of height and weight measurements from 3958 children and adolescents aged 2 to 19 years and 4431 adults aged 20 years or older obtained in 2003-2004 as part of the National Health and Nutrition Examination Survey (NHANES), a nationally representative sample of the US population. Data from the NHANES obtained in 1999-2000 and in 2001-2002 were compared with data from 2003-2004.Main Outcome MeasuresEstimates of the prevalence of overweight in children and adolescents and obesity in adults. Overweight among children and adolescents was defined as at or above the 95th percentile of the sex-specific body mass index (BMI) for age growth charts. Obesity among adults was defined as a BMI of 30 or higher; extreme obesity was defined as a BMI of 40 or higher.ResultsIn 2003-2004, 17.1% of US children and adolescents were overweight and 32.2% of adults were obese. Tests for trend were significant for male and female children and adolescents, indicating an increase in the prevalence of overweight in female children and adolescents from 13.8% in 1999-2000 to 16.0% in 2003-2004 and an increase in the prevalence of overweight in male children and adolescents from 14.0% to 18.2%. Among men, the prevalence of obesity increased significantly between 1999-2000 (27.5%) and 2003-2004 (31.1%). Among women, no significant increase in obesity was observed between 1999-2000 (33.4%) and 2003-2004 (33.2%). The prevalence of extreme obesity (body mass index ≥40) in 2003-2004 was 2.8% in men and 6.9% in women. In 2003-2004, significant differences in obesity prevalence remained by race/ethnicity and by age. Approximately 30% of non-Hispanic white adults were obese as were 45.0% of non-Hispanic black adults and 36.8% of Mexican Americans. Among adults aged 20 to 39 years, 28.5% were obese while 36.8% of adults aged 40 to 59 years and 31.0% of those aged 60 years or older were obese in 2003-2004.ConclusionsThe prevalence of overweight among children and adolescents and obesity among men increased significantly during the 6-year period from 1999 to 2004; among women, no overall increases in the prevalence of obesity were observed. These estimates were based on a 6-year period and suggest that the increases in body weight are continuing in men and in children and adolescents while they may be leveling off in women.
9,278 citations
TL;DR: There is a strong and probably causal relation between gastroesophageal reflux and esophageaal adenocarcinoma, and the relation between reflux And gastric cardia is relatively weak.
Abstract: Background The causes of adenocarcinomas of the esophagus and gastric cardia are poorly understood. We conducted an epidemiologic investigation of the possible association between gastroesophageal reflux and these tumors. Methods We performed a nationwide, population-based, case–control study in Sweden. Case ascertainment was rapid, and all cases were classified uniformly. Information on the subjects' history of gastroesophageal reflux was collected in personal interviews. The odds ratios were calculated by logistic regression, with multivariate adjustment for potentially confounding variables. Results Of the patients interviewed, the 189 with esophageal adenocarcinoma and the 262 with adenocarcinoma of the cardia constituted 85 percent of the 529 patients in Sweden who were eligible for the study during the period from 1995 through 1997. For comparison, we interviewed 820 control subjects from the general population and 167 patients with esophageal squamous-cell carcinoma. Among persons with recurrent sy...
2,949 citations
TL;DR: Results add further support to previous studies for the clinical utility of the Los Angeles system for endoscopic grading of oesophagitis and to the risk for symptom relapse off therapy over six months.
Abstract: 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)
1,994 citations
TL;DR: The prevalence and incidence of gastro-oesophageal reflux disease was estimated from 15 studies which defined GORD as at least weekly heartburn and/or acid regurgitation and met criteria concerning sample size, response rate, and recall period.
Abstract: A systematic review of the epidemiology of gastro-oesophageal reflux disease (GORD) has been performed, applying strict criteria for quality of studies and the disease definition used. The prevalence and incidence of GORD was estimated from 15 studies which defined GORD as at least weekly heartburn and/or acid regurgitation and met criteria concerning sample size, response rate, and recall period. Data on factors associated with GORD were also evaluated.
An approximate prevalence of 10–20% was identified for GORD, defined by at least weekly heartburn and/or acid regurgitation in the Western world while in Asia this was lower, at less than 5%. The incidence in the Western world was approximately 5 per 1000 person years. A number of potential risk factors (for example, an immediate family history and obesity) and comorbidities (for example, respiratory diseases and chest pain) associated with GORD were identified.
Data reported in this systematic review can be interpreted with confidence as reflecting the epidemiology of “true” GORD. The disease is more common in the Western world than in Asia, and the low rate of incidence relative to prevalence reflects its chronicity. The small number of studies eligible for inclusion in this review highlights the need for global consensus on a symptom based definition of GORD.
The study of the epidemiology of GORD is restricted by the lack of consensus over the basic definition of the disease. To review the global epidemiology of GORD is currently problematic as there is no internationally applied definition, although the need for this has been recognised.1 Gastro-oesophageal reflux manifests as a continuum of symptom frequency and/or severity in the general population. Occasional symptoms are experienced by a large proportion of the population but GORD results from frequent or severe symptoms which are sufficient to impair the individual’s health related quality of life …
1,753 citations