Special Lecture(2) : NERD-The New Face of GERD

( Ronnie Fass ) 대한소화관운동학회 2004 심포지움 Vol.10 No.1

Special Lecture 2 : NERD - The New Face of GERD

( Ronnie Fass ) 대한소화기학회 2004 대한소화기학회 춘계학술대회 Vol.2004 No.-

Non-erosive reflux disease has been defined as individuals who satisfy the definition of gastroesophageal reflux disease but do not have either Barrett`s esophagus or definite endoscopic esophageal breaks (Dent et al. Gut, 1999;44 (suppl 2):S1). Other have defined NERD as burning retrosternal discomfort for at least three months, but with normal esophageal mucosal on endoscopy (Waring JP. Semin Gastroenterol Dis, 2001). In the United States the prevalence of NERD in community-based patients has been suggested to be 53% as compared to 90% in Asia and approximately 70% in Europe. The clinical characteristics of patients with NERD as compared to those with erosive esophagitis suggests that these patient tend to be female, with lower mean weight, shorter duration of GERD symptoms and less commonly have hiatal hernia (25%). There is no difference between NERD and those with erosive esophagitis in relation to mean age, smoking, alcohol consumption and prevalence of Helicobacter pylori infection. The physiological characteristics of patients with NERD as compared to normal controls demonstrate that the resting basal LES pressure is normal, distal amplitude contractions are slightly reduced and esophageal motility abnormalities are slightly increased. The extent of acid exposure in the distal esophagus assessed by percent total time pH<4 is slightly increased, supine time pH<4 is slightly increased and upright time pH<4 is slightly increased. There is no difference in the mean gastric bile acid concentration between patients with NERD and normal subjects. Overall, therapeutic trials in patients with NERD demonstrated a lower efficacy for PPIs in symptom control than what has been previously reported in patients with erosive esophagitis. It is apparent from the different U.S. based therapeutic studies that the symptom response rate of NERD patients to PPI therapy is 10-30% less than what has been observed in patients with erosive esophagitis. Unexpectedly, the proportion of NERD patients with complete control of heartburn after 4 weeks of treatment with standard dose PPI was in accordance with their pretreatment level of esophageal acid exposure. That is, 58 the higher the acid exposure in the distal esophagus, the greater the number of patients who achieved complete control of their heartburn symptoms. The reason for the unpredictable response of NERD patients to PPI therapy is due to the fact that this is a heterogeneous group of patients with different reasons for heartburn symptoms. Between 30 and 50% of the NERD patients have distal esophageal acid exposure within the normal range. Those individuals with normal endoscopy and negative 24-hour esophageal pH monitoring have been termed as having functional heartburn. The Rome II Committee of Functional Esophageal Disorders defined functional heartburn as at least 12 weeks that need not be consecutive, in the preceding 12 months of burning, retrosternal discomfort or pain, an absence of pathologic gastroesophageal reflux, achalasia, or other motility disorder with recognized pathologic basis. Of those with normal acid exposure in the distal esophagus, 37% are considered as having the hypersensitive esophagus, which is suggestive of close correlation between patient symptoms and acid reflux events despite an acid exposure within the physiological range. An additional 63% of the subjects were considered having non-acid related heartburn (Martinez et al., Aliment Pharmacol Ther, 2003). Knowing the limited repertoire of symptoms of the esophagus, one should consider symptoms as common pathway for a variety of intra-esophageal stimuli. In the esophagus, symptoms do not appear to be stimulus specific. Thus the axiom No Acid, No Heartburn: should be obsolete. The potential mechanism for non-acid related heartburn symptoms may include motor events (sustained esophageal contractions (?), non-acidic reflux and minute pH changes that do not reach the traditional required threshold for the

Noncardiac Chest Pain: Epidemiology, Natural Course and Pathogenesis

( Ronnie Fass ),( Sami R Achem ) 대한소화기기능성질환·운동학회(구 대한소화관운동학회) 2011 Journal of Neurogastroenterology and Motility (JNM Vol.17 No.2

Noncardiac chest pain is defined as recurrent chest pain that is indistinguishable from ischemic heart pain after a reasonable workup has excluded a cardiac cause. Noncardiac chest pain is a prevalent disorder resulting in high healthcare utilization and significant work absenteeism. However, despite its chronic nature, noncardiac chest pain has no impact on patients` mortality. The main underlying mechanisms include gastroesophageal reflux, esophageal dysmotility and esophageal hypersensitivity. Gastroesophageal reflux disease is likely the most common cause of noncardiac chest pain. Esophageal dysmotility affects only the minority of noncardiac chest pain patients. Esophageal hypersensitivity may be present in non-GERD-related noncardiac chest pain patients regardless if esophageal dysmotility is present or absent. Psychological co-morbidities such as panic disorder, anxiety, and depression are also common in noncardiac chest pain patients and often modulate patients` perception of disease severity. (J Neurogastroenterol Motil 2011;17:110-123)

Diagnosis and Management of Functional Chest Pain in the Rome IV Era

Ronnie Fass,Fahmi Shibli,Jose Tawil 대한소화기 기능성질환∙운동학회 2019 Journal of Neurogastroenterology and Motility (JNM Vol.25 No.4

Functional chest pain accounts for about a third of the patients with noncardiac chest pain. It is a very common functional esophageal disorder that remains even today a management challenge to the practicing physician. Based on the definition offered by the Rome IV criteria, diagnosis of functional chest pain requires a negative workup of noncardiac chest pain patients that includes, proton pump inhibitor test or empirical proton pump inhibitor trial, endoscopy with esophageal mucosal biopsies, reflux testing, and esophageal manometry. The mainstay of treatment are neuromodulators that are primarily composed of anti-depressants. Alternative medicine and psychological interventions may be provided alone or in combination with other therapeutic modalities.

Case Report : Progression of Jackhammer Esophagus to Type II Achalasia

( Jason Abdallah ),( Ronnie Fass ) 대한소화기기능성질환·운동학회(구 대한소화관운동학회) 2016 Journal of Neurogastroenterology and Motility (JNM Vol.22 No.1

It has been suggested that patients with certain motility disorders may progress overtime to develop achalasia. We describe a 66 year-old woman who presented with dysphagia for solids and liquids for a period of 18 months. Her initial workup showed normal endoscopy and non-specific esophageal motility disorder on conventional manometry. Six months later, due to persistence of symptoms, the patient underwent a high resolution esophageal manometry (HREM) demonstrating jackhammer esophagus. The patient was treated with a high dose proton pump inhibitor but without resolution of her symptoms. During the last year, the patient reported repeated episodes of food regurgitation and a significant weight loss. A repeat HREM revealed type II achalasia. Multiple case reports, and only a few prospective studies have demonstrated progression from certain esophageal motility disorders to achalasia. However, this report is the first to describe a case of jackhammer esophagus progressing to type II achalasia. (J Neurogastroenterol Motil 2016;22:153-156)

Reflux Hypersensitivity: A New Functional Esophageal Disorder

( Takahisa Yamasaki ),( Ronnie Fass ) 대한소화기기능성질환·운동학회(구 대한소화관운동학회) 2017 Journal of Neurogastroenterology and Motility (JNM Vol.23 No.4

Reflux hypersensitivity, recently introduced by Rome IV as a new functional esophageal disorder, is currently considered as the presence of typical heartburn symptoms in patients with normal upper endoscopy and esophageal biopsies, normal esophageal pH test and with evidence of a close correlation between patients’ heartburn and reflux events. Reflux hypersensitivity is very common and together with functional heartburn accounts for more than 90% of the heartburn patients who failed treatment with proton pump inhibitor twice daily. In addition, reflux hypersensitivity affects primarily young to middle aged women, commonly overlaps with another functional gastrointestinal disorders, and is often associated with some type of psychological comorbidity. Diagnosis is made by using endoscopy with esophageal biopsies, pH-impedance, and high-resolution esophageal manometry. Reflux hypersensitivity is primarily treated with esophageal neuromodulators, such as tricyclic anti-depressants and selective serotonin reuptake inhibitors among others. Surgical anti-reflux management may also play an important role in the treatment of reflux hypersensitivity. (J Neurogastroenterol Motil 2017;23:495-503)

Editorial : The Overlap Between GERD and Functional Bowel Disorders-When East Meets Rome

( Tiberiu Hershcovici ),( Ronnie Fass ) 대한소화관운동학회 2010 Journal of Neurogastroenterology and Motility (JNM Vol.16 No.2

Review : Nonerosive Reflux Disease (NERD)-An Update

( Tiberiu Hershcovici ),( Ronnie Fass ) 대한소화관운동학회 2010 Journal of Neurogastroenterology and Motility (JNM Vol.16 No.1

Recognizing nonerosive reflux disease (NERD) as a distinct presentation of gastroesophageal reflux disease (GERD) was one of the most important developments in the field of GERD in the Last decade. Whilst the definition of NERD has not changed significantly over the years, the disorder accounts for the majority of the GERD patients and those who failed proton pump inhibitor (PPI) treatment. Recent developments in NERD focused primarily on understanding the pathophysiology and natural history. The introduction of esophageal impedance + pH has Led to the assessment of other forms of gastroesophageal reflux in causing NERD. Therapeutic modalities still focus on acid suppression, but there is growing recognition that other therapeutic strategies should be considered in NERD.(J Neurogastroenterol Motil 2010;16:8-21)

Progression of Jackhammer Esophagus to Achalasia: Author’s Reply

Jason Abdallah,Ronnie Fass 대한소화기 기능성질환·운동학회 2016 Journal of Neurogastroenterology and Motility (JNM Vol.22 No.2

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Alteration in Integrated Relaxation Pressure During Successive Swallows in Subjects With Normal Manometry Versus Those With Esophagogastric Junction Outflow Obstruction

( Abbinaya Elangovan ),( Fahmi Shibli ),( Ronnie Fass ) 대한소화기기능성질환·운동학회(구 대한소화관운동학회) 2021 Journal of Neurogastroenterology and Motility (JNM Vol.27 No.2

Background/Aims Integrated relaxation pressure (IRP) is defined as the average minimum esophagogastric junction pressure for 4 seconds of relaxation (contiguous or noncontiguous) within 10 seconds of swallowing. The durability of IRP values during successive swallows in the supine position remains to be elucidated. The aim is to determine alteration in IRP values during successive swallows among subjects with normal esophageal manometry versus those with esophagogastric junction outflow obstruction (EGJOO). Methods Consecutive subjects, who underwent high-resolution esophageal manometry (HREM) were included in the study. Individuals had to have either normal manometry or EGJOO. A total of 10 wet swallows of 5 mL water were performed after an adaptation period of a minimum of 3 minutes. Mean IRP was analyzed for both subject groups for each individual swallow. Results Thirty-one patients with EGJOO and seventy patients with normal manometry were included. As expected, the median IRP was higher in EGJOO patients compared to those with normal HREM (mean: 23.92 vs 5.34, P < 0.001). The mean IRP of the last swallow was 40% lower than the mean IRP of the first swallow in the normal subjects (P = 0.015). In contrast, the difference in the mean IRP value in the EGJOO group between the first and the last swallow was 19% (P = 0.018). Conclusions This study demonstrated that there is a significant decline in the mean IRP during successive swallows in subjects with normal esophageal manometry and those with EGJOO, despite adequate adaptation periods. This decline in IRP was less pronounced in EGJOO. (J Neurogastroenterol Motil 2021;27:185-190)