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GERD according with the gold standard approach. Patients were first classified depending on the clinical presentation. Those with troublesome GERD symptoms (group 1) were considered to have GERD independently of the complementary investigation. Patients with non-troublesome GERD symptoms (group 2) or without symptoms (group 3) were considered to have GERD in the presence of objective GERD parameters seen at endoscopy or pH-metry
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Gastroesophageal reflux disease (GERD) has been increasingly recognized in patients with morbid obesity. A recent global evidence-based consensus on GERD has been proposed, but its performance in patients with morbid obesity is unknown. The aim of this study was to assess the performance of the Montreal Consensus in the diagnosis of GERD in morbidl...
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Background/aims:
Neurologically impaired patients frequently suffer from gastrointestinal tract problems, such as gastroesophageal reflux disease (GERD). In this study, we aimed to define the risk factors for GERD in neurologically impaired children.
Methods:
From May 2006 to March 2014, 101 neurologically impaired children who received 24-hour...
Reflux esophagitis is inversely associated with the presence of atrophic gastritis, and endoscopic grading of atrophic gastritis correlates with histological evaluation. The aim of this study was to investigate the association of the endoscopic grade of atrophic gastritis with gastroesophageal and gastropharyngeal reflux.
A total of 627 patients, w...
Eosinophilic esophagitis (EoE) is a chronic, immune/antigen-mediated esophageal disease characterized by symptoms related to esophageal dysfunction, eosinophil-predominant inflammation, and lack of response to high-dose proton pump inhibitor (PPI) therapy. Responsiveness to PPI therapy in patients with suspected EoE has been historically assumed as...
Despite the wealth of publications on the topic of gastroesophageal reflux and its variants, there are still many unsettled questions before one accepts the prevalent cult of "reflux disease". This study is summarizing the results of the critical analysis of the literature, 436 articles,during the last 30 years. The golden test to identify the pati...
PH monitoring is not capable of detecting all types of reflux, especially when the amount of acid is very low or not at all in the refluxate. Multichannel intraluminal impedance-pH monitoring (MII-pH) is used as a new method to assess bolus transport. The types of reflexes including acid, weak acid and weak alkaline MII-pH is capable of distinguish...
Citations
... Further arguing for routine p-EGD is the poor correlation between preprocedural symptoms and EGD findings. A review of seven studies totaling 729 asymptomatic patients found a hiatal hernia, erosive esophagitis, and Barrett's esophagus in 17%, 16.9%, and 0.7%, respectively [32][33][34][35][36][37][38]. Moreover, continuous ambulatory pH monitoring in asymptomatic patients has shown pathologic acid reflux in up to 59% of patients. ...
... One may argue that the clinical scenario is different in this patient population, as they are known to be symptomatic (i.e., report heartburn, reflux). However, it has been consistently shown that there is poor correlation between symptoms and findings of reflux [24,[32][33][34][35][36][37][38]. ...
Introduction:
Our aim was to evaluate the diagnostic yield of routine preoperative esophagogastroduodenoscopy (p-EGD) in patients undergoing bariatric surgery. Many medical problems that are common in patients with obesity, including gastroesophageal reflux disease (GERD) and hiatal hernias, have important implications for patients undergoing bariatric surgery. While p-EGD is considered standard of care prior to antireflux surgery, the role of p-EGD in bariatric surgery patients remains controversial.
Methods and procedures:
We performed a retrospective chart review of 885 patients who underwent primary bariatric surgery at a university hospital-based bariatric surgery program between March 2011 and February 2022. Clinical history, demographics, and preoperative EGD reports were reviewed for abnormal findings.
Results:
Of the 885 patients evaluated in this study, one or more abnormal EGD findings were observed in 83.2% of patients. More than half of our patients (54.7%) presented with history of heartburn, reflux, or GERD. EGD findings demonstrated a hernia in 43.1% of patients [(Type I: 40.6%; Type II: 0.5%; Type III: 2.1%)]. 68.0% of patients were biopsied. Among patients who were biopsied, other findings included gastritis (32.4%), esophagitis (8.0%), eosinophilic esophagitis (4.7%), or duodenitis (2.7%). We found ulcers in 6.7% of patients. Pathology was consistent with H. pylori in 9.8% of biopsies taken and consistent with BE in 2.7%. Following routine p-EGD, 11.2% of patients were placed on PPI and 8.3% were recommended to stop NSAIDs.
Conclusion:
Gastroesophageal reflux disease and associated pathology are common in the bariatric population. Preoperative EGD in patients undergoing bariatric surgery frequently identifies clinically significant UGI pathology. This may have important implications for medical and surgical management. Given the rate of abnormal preoperative endoscopic findings in obese patients, the work-up for bariatric surgery should align with the current recommendations for foregut surgery.
... However, whether patients with T2DM scheduled for bariatric surgery have a higher prevalence of GERD than those without T2DM is uncertain. Further, it is well known that GERD symptoms and endoscopic findings are weakly correlated [16][17][18][19] but the relationship between esophagitis and GERD symptoms in patients with or without T2DM has not been well investigated [10,20]. In addition, few previous studies have assessed the association between esophageal acid exposure and reflux symptoms or erosive esophagitis in subjects with severe obesity [10,21,22]. ...
... To show a mean (SD) clinically meaningful difference of at least 10 [20] GSRS score points between groups with or without T2DM (power 80% and alpha 0.05), at least 44 patients without T2DM had to be included. Taking into account possible loss to follow-up and incomplete data, a total of 64 controls without T2DM were included. ...
Background
Type 2 diabetes (T2DM) is associated with gastroesophageal reflux disease (GERD) in the general population, but the relationship between these conditions in candidates for bariatric surgery is uncertain. We compared the prevalence of GERD and the association between GERD symptoms and esophagitis among bariatric candidates with and without T2DM.Methods
Cross-sectional study of baseline data from the Oseberg study in Norway. Both groups underwent gastroduodenoscopy and completed validated questionnaires: Gastrointestinal Symptom Rating Scale and Gastroesophageal Reflux Disease Questionnaire. Participants with T2DM underwent 24-h pH-metry.ResultsA total of 124 patients with T2DM, 81 women, mean (SD) age 48.6 (9.4) years and BMI 42.3 (5.5) kg/m2, and 64 patients without T2DM, 46 women, age 43.0 (11.0) years and BMI 43.0 (5.0) kg/m2, were included. The proportions of patients reporting GERD-symptoms were low (< 29%) and did not differ significantly between groups, while the proportions of patients with esophagitis were high both in the T2DM and non-T2DM group, 58% versus 47%, p = 0.16. The majority of patients with esophagitis did not have GERD-symptoms (68–80%). Further, 55% of the patients with T2DM had pathologic acid reflux. Among these, 71% also had erosive esophagitis, whereof 67% were asymptomatic.Conclusions
The prevalence of GERD was similar in bariatric patients with or without T2DM, and the proportion of patients with asymptomatic GERD was high independent of the presence or absence of T2DM. Accordingly, GERD may be underdiagnosed in patients not undergoing a preoperative endoscopy or acid reflux assessment.Trial RegistrationClinical Trials.gov number NCT01778738
... Gastroesophageal reflux disease (GERD) and obesity are highly prevalent and frequently associated diseases [2]. Typical GERD symptoms have shown limited accuracy to indicate the presence of GERD either among obese patients or after bariatric surgery [3][4][5]. The Lyon consensus [6] describes currently accepted diagnostic criteria for GERD and emphasizes objective parameters for GERD in general practice and research. ...
Objective
To evaluate the impact of laparoscopic sleeve gastrectomy (LSG) or laparoscopic Roux-en-Y gastric bypass (LRYGB) on gastroesophageal reflux disease (GERD) in patients with obesity.
Methods
Patients with class II or III obesity were treated with LSG or LRYGB. Procedure choice was based on patients and surgeon preferences. GERD symptoms, endoscopy, barium swallow X-ray, esophageal manometry, and 24-h pH monitoring were obtained before and 1 year after surgery.
Results
Seventy-five patients underwent surgery (83% female, 39.3 ± 12.1 years, BMI of 41.5 ± 5.1 kg/m²): 35 (46.7%) had LSG and 40 (53.3%) LRYGB. LSG patients had lower BMI (40.3 ± 4.0 kg/m² vs. 42.7 ± 5.7 kg/m²; p = 0.041) and trend toward lower prevalence of GERD (20% vs. 40%; p = 0.061). One year after surgeries, GERD was more frequent in LSG patients (74% vs. 25%; p < 0.001) and all LSG patients with preoperative GERD continue to have GERD postoperatively. De novo GERD occurred in 19 of 28 (67.9%) of LSG patients and 4 of 24 (16.7%) patients treated with LRYGB (OR 10.6, 95%CI 2.78–40.1). Independent predictors for post-operative GERD were as follows: LSG (OR 12.3, 95%CI 2.9–52.5), preoperative esophagitis (OR 8.5, 95% CI 1.6–44.8), and age (OR 2.0, 95%CI 1.1–3.4).
Conclusions
One year after surgery, persistent or de novo GERD were substantially more frequent in patients treated with LSG compared with LRYGB. LSG was the strongest predictor for GERD in our trial. Preoperative counseling and choice of bariatric surgical options must include a detailed assessment and discussion of GERD-related surgical outcomes.
... GERD diagnosis based solely on clinical evaluation has been proven to yield inaccurate results in individuals with and without obesity [5][6][7] . Studies in patients with severe obesity have shown that up to about 50% of patients without troublesome symptoms may indeed have esophagitis and/or abnormal acid reflux, as well as GERD symptoms with normal endoscopy and/or normal esophageal pH test [3,8] . ...
Background:
Gastroesophageal reflux disease (GERD) impacts choice and outcomes of bariatric surgery. However, GERD diagnosis based solely on symptoms yields inaccurate results.
Objective:
To determine the factors associated with a positive 24h pH-monitoring (pH-test) or esophagitis in patients with severe obesity seeking bariatric surgery.
Setting:
Private practice.
Methods:
93 patients with severe obesity underwent prospective evaluation for GERD symptoms, body composition, upper gastrointestinal endoscopy, esophageal manometry and pH-test. Correlation analyses were performed.
Results:
50 patients (53.8%) had GERD symptoms, 49 (52.7%) had esophagitis and 33 (35.5%) had a positive pH-test. Among patients with GERD symptoms, 18% had normal pH-test and no esophagitis, while 34.9% of patients without GERD symptoms had positive pH-test, esophagitis or both. Factors independently associated with positive pH-test were esophagitis (PR:3.08, 95%CI: 1.4-6.9, P = 0.006) and defective lower esophageal sphincter (PR:1.88, 95%CI: 1.09-3.21, P = 0.02). Factors independently associated with esophagitis were hiatal hernia (PR: 2.46; 95%CI: 1.6-3.7, P<0.001), GERD symptoms (PR:2.09; 95%CI: 1.3-3.4, P = 0.003) and positive pH-test (PR:1.82; 95%CI: 1.2-2.7, P = 0.003). The combined presence of GERD symptoms and esophagitis had a low positive predictive value for a positive pH-test (57%). On the other hand, the absence of both GERD symptoms and esophagitis had a 90% predictive value for a negative pH-test.
Conclusions:
Investigation for GERD before bariatric surgery should consist of routine upper endoscopy and GERD symptom evaluation in all patients. Patients with GERD symptoms and no esophagitis may need a pH-test for GERD diagnosis. Prospective studies are needed to understand significance of GERD diagnosis prior to bariatric surgery.
... In contrast to an increasing prevalence of objective findings of GERD in obese patients with symptoms [20], no significant difference of imp-pH findings have been shown in others [21]. In addition, asymptomatic gastroesophageal reflux seems to be more common than symptomatic gastroesophageal reflux in patients with severe obesity, while the evaluation of GERD solely by symptoms seems inadequate [22,23]. ...
... Current findings are similar to previously reported frequencies of erosive GERD in obese patients [20][21][22][23]. In the group of patients studied by Ortiz et al., 84/138 (60.9%) patients had troublesome GERD symptoms or objective evidence of GERD and 38/138 (27.5%) patients had only an abnormal 24-h pH study in support of GERD. ...
Background:
Gastroesophageal reflux disease (GERD) is common in patients with obesity. Diagnosing GERD is important as bariatric operations have different influence on GERD. We assessed reflux symptoms and objective findings prior to surgery.
Methods:
Work-up included esophageal symptoms quantification by VAS-scores, esophagogastroduodenoscopy (EGD) and 24-h impedance-pH (imp-pH) monitoring off PPI therapy. Imp-pH was classified as abnormal if either %time pH<4 was abnormal, total number of reflux episodes was elevated or symptom index (SI) was positive.
Results:
Among 100 consecutive patients (68F, age 40±11years, BMI 44.9±6.9kg/m(2)) 54% reported heartburn and/or regurgitation, 71% had objective evidence of GERD (38% endoscopic lesions and 33% only abnormal imp-pH results). Imp-pH was superior to EGD in identifying GERD (sensitivity 85% vs. 54%, p<0.01). Symptomatic and asymptomatic patients had similar prevalence of esophageal lesions (37% vs. 39%) and abnormal imp-pH findings (68% vs. 50%). Sixty nine percent of patients with abnormal %time pH<4 had a normal number of reflux episodes.
Conclusion:
Half of patients with obesity reported typical GERD symptoms and >70% had evidence of GERD. Poor acid clearance was the main mechanisms. Since typical reflux symptoms don't predict objective findings, endoscopy and reflux monitoring should be part of the surgery work-up especially before restrictive procedures.
... According to Montreal consensus, GERD is defined as a condition which develops when the reflux of gastric content causes troublesome symptoms and/or complications [2]. Montreal definition of GERD has been tested before in obese population and has been found to have a specificity of 100 % [3]. ...
Although several studies reporting normal values of 24h multichannel intraluminal impedance pH (MIIpH) have been published, none of them has ever studied obese individuals. The purpose of this study is to determine overall frequency and duration of reflux episodes (acid and non-acid, supine-upright, post and preprandial) in obese asymptomatic volunteers.
Obese volunteers were enlisted during their preoperative evaluation for bariatric surgery. Volunteers had no gastroesophageal reflux disease (GERD) symptoms and no evidence of esophageal mucosal injury on endoscopy. Participants underwent a 24h MIIpH.
In this prospective observational study, data of 22 obese individuals were analyzed. Mean age was 41.9 years and mean BMI was 47.1 kg/m(2). Mean total reflux episodes was 55.6 and 95th percentile was 99.7. Mean percentage of total time with pH <4 was 2.59 % and 95th percentile was 8.57 %. Mean percentage of bolus exposure was 1.84 % with 95th percentile being 4.47 %. Postprandial acid reflux episodes were statistical significant more frequent in comparison to preprandial acid reflux episodes (19.41 vs. 15, p = 0.008). Mean acid clearance duration was 3.6 times higher than median bolus clearance duration (56.05 and 15.55 s, respectively, p = 0.868).
Our study is the first to provide normal values of 24h MIIpH of asymptomatic obese. Normal values of 24h MIIpH of obese asymptomatic individuals differ from the reported normal values of non-obese healthy individuals; having more reflux episodes and equal or slightly higher median bolus exposure and acid clearance. Our results imply that new cut-off values should be employed in order to define GERD in obese individuals.
... To what extent this is representative of the diagnosis obtained using invasive physiological tests is uncertain. Despite the fact that a recent study reported a low sensitivity for clinical diagnosis based on the Montreal Consensus in obese patients [32], the use of the RDQ for symptom-based diagnosis of GERD in the primary-care setting has been clinically validated [16], and all clinical guidelines support symptom-based diagnosis of GERD. ...
Scales for aiding physicians diagnose gastro-oesophageal reflux disease (GERD) have not been evaluated in terms of their ability to discriminate between troublesome symptoms (TS) and non-troublesome symptoms (NTS). Our objective is to evaluate the ability of the Reflux Disease Questionnaire (RDQ) to identify GERD according to referral of TS, in patients without previous proton pump inhibitor (PPI) treatment and in patients on PPI treatment.
Patients consulting physicians because of heartburn or acid regurgitation were recruited at 926 primary-care centres in Spain. They were asked to complete several questionnaires including the RDQ, and to define which of their symptoms were troublesome. Information on drug treatment was collected by the physician. We performed a receiver operating characteristic (ROC) curve analysis to ascertain the RDQ's optimum cut-point for identifying TS.
4574 patients were included, 1887 without PPI and 2596 on PPI treatment. Among those without PPI treatment, 1722 reported TS. The area under the curve (AUC) was 0.79 for the RDQ, and the optimum RDQ cut-point for identifying TS was 3.18 (sensitivity, 63.2%; specificity, 80.2%). A total of 2367 patients on PPI treatment reported TS, and the optimum RDQ cut-off value was 3.06 (sensitivity, 65.4%; specificity, 71.8%).
An RDQ score higher than 3 shows good sensitivity and specificity for differentiating TS from NTS among patients without PPI or on PPI treatment. The RDQ is useful in primary care for diagnosis of GERD based on the Montreal definition.
... Le RGO est défini d'après la conférence de consensus de Montréal (119) comme une « condition qui se développe lorsque le reflux du contenu gastrique entraine des symptômes et/ou des complications. » (79). Ce reflux peut être d'origine gastrique ou duodénale. ...
Le but de ce travail était d'étudier de façon prospective, la relation entre obésité et RGO chez 250 patients atteints d'une obésité sévère ou morbide, référés pour réalisation d'une FOGD avant chirurgie bariatrique. Nous souhaitions évaluer si l'obésité était responsable d'une prévalence accrue de symptômes, et d'une augmentation de leur intensité, de leur fréquence ou encore de lésions oesophagiennes telles que l'oesophagite, l'EBO et l'adénocarcinome de l'oesophage comme le suggèrent les études Nord Américaines. Notre étude a été réalisée sur une population composée de 82% de femmes, avec un âge moyen de 38.8 ans et un IMC moyen à 43.3 kg/m2. Elle a mis en évidence des symptômes de RGO chez 38% des patients et un taux d'oesophagite de 4.8%, grade A de la classification de Los Angeles chez 11 de ces 12 patients. Aucun cas d'EBO et ni aucun cas d'adénocarcinome de l'oesophage n'a été observé. Ce travail remet en question l'association entre l'obésité évaluée par l'IMC ou la mesure du périmètre abdominal et RGO. En d'autres termes, l'obésité ne semble pas augmenter le risque de RGO ni de lésions oesophagiennes. Des études supplémentaires sont cependant nécessaires pour évaluer l'effet de la graisse viscérale sur le RGO, notamment via son activité métabolique.
... Although most studies have used X-ray or endoscopy to characterize SHH, no technique has reached a consensus in terms of diagnostic capability. GORD is highly prevalent in patients with severe obesity [34][35][36], which is characterized by a BMI greater than 35 kg/m 2 [37]. It has been shown that these patients have an increased GOPG compared with lean individuals [24], as well as an expectedly higher frequency of SHH. ...
The relationship between gastro-oesophageal pressure gradient (GOPG), sliding hiatal hernia (SHH) and gastro-oesophageal reflux disease (GORD) is under investigation. We assessed whether GOPG and SHH are predictors of pathological reflux in severely obese patients.
Ninety-four consecutive patients were prospectively studied with oesophageal manometry, 24-h pH monitoring, upper gastrointestinal endoscopy and barium swallow X-ray. Inspiratory and expiratory GOPGs were measured at manometry testing, whereas SHH was characterized by X-ray. Patients were classified as having physiological or pathological reflux depending on pH monitoring. Patients with oesophagitis but normal pH testing were excluded.
Eighty-nine patients composed the study sample (25 men, 38.3+/-11.1 years; BMI 45+/-6.9 kg/m). Sixty-two patients (70%) had pathological reflux, whereas 27 patients (30%) had physiological reflux. Pathological reflux was predicted either by inspiratory GOPG [prevalence ratio (PR) =1.05; 95% confidence interval (CI): 1.03-1.08; P<0.001] or by expiratory GOPG (PR=1.07; 95% CI: 1.03-1.11; P=0.001). Accordingly, an increment of 1 mmHg in inspiratory and expiratory GOPGs raises the risk of pathological reflux in 5 and 7%, respectively. Pathological reflux was also predicted by SHH (PR: 1.54, 95% CI: 1.19-2.00; P=0.001), which increases the risk of abnormal reflux in 54%.
In severely obese patients, either inspiratory GOPG, expiratory GOPG or SHH are predictors of pathological reflux. These findings give pathophysiological support to the high prevalence of GORD in this population.
... It showed limited sensitivity to detect GERD, as patients who denied reflux symptoms still had reflux esophagitis (RE) or increased acid exposure. 13 GERD has some peculiarities in patients with morbid obesity. Its higher prevalence highlights the importance of the stress over the gastroesophageal junction related with severe overweight. ...
To assess the impact of gastric bypass (GBP) on gastroesophageal reflux disease (GERD) based on Montreal Consensus.
In this study, 86 patients (25 men; aging 38 +/- 12 years; body mass index 45 [35-68 kg/m2]) were investigated for GERD before GBP and 6 months later. Esophageal and extraesophageal syndromes were assessed based on Montreal Consensus. Esophageal acid exposure and gastric pouch acidity were also evaluated.
Overall prevalence of GERD was 64% before GBP and 33% after GBP (P < 0.0001). Typical reflux syndrome (TRS) was present in 47 patients (55%) preoperatively and disappeared in 39 of them (79%) post-GBP. Out of 39 patients with no symptoms, 4 (10%) developed TRS postoperatively (P < 0.0001). The chief TRS complaint changed from heartburn pre-GBP (96%) to regurgitation post-GBP (64%). Esophageal mucosa improved in 27, was unchanged in 51, and worsened in 8 patients (P = 0.001) in regard of esophagitis. Extraesophageal syndromes were present in 16 patients preoperatively and in none but one post-GBP (P = 0.0003). GERD-related well being and use of proton pump inhibitors were both improved after GBP. Total acid exposure decreased from a median (interquartile range, 25%-75%) of 5.1% (range, 2-8.2) to 1.1% (range, 0.2-4.8), P = 0.0002. Most patients (86%) showed and acid gastric pouch in fasting conditions post-GBP.
GBP ameliorated GERD syndromes in most patients 6 months after the procedure, resulting in quality of life improvement and less proton pump inhibitors usage. Whether regurgitation post-GBP corresponds to reflux disease or bad eating behavior deserves further studies.
