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Aliment Pharmacol Ther 2011; 34: 487-493 Summary Background Erosive oesophagitis appears to be more common in white vs. nonwhite patients with gastro-oesophageal reflux disease (GERD). Aim To evaluate the association between race and erosive oesophagitis healing in patients with GERD treated with once-daily proton pump inhibitors (PPIs). Methods Data from five double-blind trials of once-daily treatment with esomeprazole 40 mg vs. omeprazole 20 mg or lansoprazole 30 mg for erosive oesophagitis healing (evaluated at weeks 4 and 8 by endoscopy) were pooled and stratified by baseline race and Los Angeles (LA) severity grade. Multiple logistic regression models were fit with erosive oesophagitis healing (dependent variable) and race (independent variable), with adjustments for treatment, study, baseline LA grade, age, gender, BMI, Helicobacter pylori status, hiatal hernia and interactions of these factors with race. Results Of 11 027 patients, 91% were white. Nonwhite ( n = 978) and black ( n = 613) patients were less likely to have severe baseline erosive oesophagitis (LA grade C or D) than white patients [adjusted OR: 0.69 (95% CI, 0.61-0.79) and 0.67 (0.57-0.78), respectively; P < 0.0001]. At week 8, nonwhite and black patients had lower healing rates than white patients [OR: 0.75 (0.63-0.89) and 0.67 (0.54-0.83), respectively; P ≤ 0.001]. Greater odds of healing were associated with less severe baseline LA grade, increasing age, hiatal hernia, esomeprazole treatment (vs. lansoprazole or omeprazole) and lansoprazole treatment (vs. omeprazole) (all P ≤ 0.0009); no factor interacted significantly with race. Conclusions Nonwhite patients with GERD had less severe baseline erosive oesophagitis, but were less likely than white patients to have erosive oesophagitis healing after 8-week PPI therapy. [ABSTRACT FROM AUTHOR]

Background Mechanisms of symptom perception among patients with gastro-oesophageal reflux disease (GERD) remain to be fully elucidated. Aim To correlate quantitative reflux symptom scores with microscopic oesophageal histopathology. Methods Prior to endoscopy, patients with reflux symptoms completed a validated reflux disease questionnaire (score 0-36). Erosive oesophagitis (EO) was graded using the LA classification. Oesophageal biopsies were graded 0-2 for basal cell hyperplasia, papillary elongation, dilated intercellular spaces (DIS), necrosis or erosion, eosinophils and neutrophils by a blinded gastrointestinal pathologist as previously described. Additionally, lymphocyte density was also evaluated. Pearson's correlation coefficients were computed. Results Thirty-two EO and 21 non-erosive reflux disease (NERD) patients were prospectively enrolled. For EO vs. NERD, mean reflux symptom scores (10.7 vs. 8.8, P = 0.35) and histology scores were similar (4.29 vs. 4.25; P = 0.9). However, when symptom scores were compared with histology scores, a correlation was found in the EO group, but not in the NERD group (r = 0.34, P = 0.05 vs. r = 0.22, P = 0.36). On further analysis, DIS was associated with symptom scores in the EO group (P ≤ 0.001), but not in the NERD group (P = N.S.). Similarly, lymphocyte density was associated with symptom scores in the EO group (r = 0.56, P = 0.0009), but not in the NERD group (r = 0.002, P = 0.9). Conclusions Although mean symptom and histology scores were similar in the EO and NERD groups, a significant correlation of symptom scores with histology scores, DIS and lymphocytes was found in the former, but not in the latter. EO and NERD patients may have different symptom perception mechanisms and thus, dissimilar symptom resolution rates with acid suppression. [ABSTRACT FROM AUTHOR]

The incidence of oesophageal adenocarcinoma continues to increase in the US and the Western world, with the 5-year survival rate for this cancer still being very dismal.The diagnosis of Barrett's metaplasia and dysplasia (i.e. screening and surveillance) currently requires endoscopy with biopsy of the abnormally appearing distal oesophagus. Surveillance endoscopy in patients with Barrett's oesophagus relies on the performance of random biopsies from the metaplastic segment, with the aim of identifying dysplasia and/or cancer. However, intestinal metaplasia and dysplasia are not uniformly distributed within the columnar-lined mucosa in the distal oesophagus, and the sensitivity of standard endoscopy with biopsy for the detection of these lesions is low.New techniques to improve the accuracy of endoscopic diagnosis, as well as to identify patients at high risk for neoplasia development, have recently been developed and most are currently being evaluated in clinical studies. The results with these techniques, although promising, are still preliminary. They hold promise for the improved detection of dysplasia and neoplasia at an early stage of development, with a greater chance for early treatment, and therefore a greater likelihood of either cure of adenocarcinoma or prevention of its development from dysplasia. [ABSTRACT FROM AUTHOR]

Despite implementation of screening and surveillance strategies, a significantly large number of patients with Barrett's oesophagus remain undiagnosed. In those who are identified, the management options include acid reduction therapies with proton pump inhibitors or anti-reflux surgery. Endoscopic ablative therapies have also been attempted. In addition to having inherent procedure-related risks with ablative therapies, these alternatives may be limited by high rates of failure, need for continued acid suppressive therapy, metaplasia persistence under otherwise normal appearing tissue, need for procedural expertise, and continued risk for adenocarcinoma development. Therefore, a widely applicable chemoprevention strategy that cost-effectively reduces the rate of progression from oesophagitis to adenocarcinoma in high-risk patients and perhaps those at lower rates of risk is highly desirable. The AspECT trial currently underway is seeking to determine the effects of high- and low-dose proton pump inhibitor therapy with and without low-dose aspirin as Barrett's oesophagus chemoprevention. [ABSTRACT FROM AUTHOR]

Summary A number of endoscopic techniques have been described for the treatment of reflux disease. These include endoscopic plicators, which place submucosal or transmural sutures around the lower oesophageal sphincter, the Stretta procedure, which places minute areas of thermal injury in the muscle of the lower oesophageal sphincter and cardia, and injection techniques, in which inert substances are injected into the mucosa or the muscle of the lower oesophagus. The mechanism of action of these procedures has been studied to varying degrees. The Stretta procedure is the only endoscopic technique that has been shown to be effective in a sham-controlled trial. Complication rates are generally low, but serious complications have been reported in some cases. The results with some of these techniques are promising, but all procedures described to date are limited by the absence of large, rigorously controlled trials against a form of treatment that has been proven to be both safe and effective (medical therapy). Future studies will need to use controls, validated outcome measures and pre-determined end-points and to provide comparative and long-term data. [ABSTRACT FROM AUTHOR]