Outcome of nonerosive gastro-esophageal reflux disease patients with pathological acid exposure

AIM： To assess the management and outcome of nonerosive gastro-esophageal reflux disease （NERD） patients who were identified retrospectively, after a 5-year follow-up. METHODS： We included patients with gastro-esophageal reflux disease （GERD） symptoms who had a negative endoscopy result and pathological 24-h esophageal pH-monitoring while off therapy. We interviewed them after an average period of 5 years （range 3.5-7 years） by means of a structured questionnaire to assess presence of GERD symptoms, related therapy, updated endoscopic data and other features. We assessed predictors of esophagitis development by means of univariate and multivariate statistical analysis. RESULTS： 260 patients （137 women） were included. Predominant GERD symptoms were heartburn and regurgitation in 103/260 （40%）. 70% received a maintenance treatment, which was proton pump inhibitor （PPI） in 55% of cases. An average number of 1.5 symptomatic relapses per patient/year of follow-up were observed. A progression to erosive gastro-esophageal reflux disease （ERD） was found in 58/193 （30.0%） of patients undergoing repeat endoscopy; 72% of these were Los Angeles grade A-B. CONCLUSION： This study to ERD occurs in about 5% shows that progression of NERD cases per year, despite therapy. Only two factors consistently and independently influence progression： smoking and absence of PPI therapy.

Gastroesophageal reflux disease management according to contemporary international guidelines:A translational study

AIM:To test the Genval recommendations and the usefulness of a short trial of proton pump inhibitor(PPI) in the initial management and maintenance treatment of gastroesophageal reflux disease(GERD)patients. METHODS:Five hundred and seventy seven patients with heartburn were recruited.After completing a psychometric tool to assess quality of life(PGWBI)and a previously validated GERD symptom questionnaire (QUID),patients were grouped into those with esophagitis(EE,n=306)or without mucosal damage (NERD,n=271)according to endoscopy results. The study started with a 2-wk period of high dose omeprazole(omeprazole test);patients responding to this PPI test entered an acute phase(3 mo)of treatment with any PPI at the standard dose.Finally,those patients with a favorable response to the standard PPI dose were maintained on a half PPI dose for a further 3-mo period. RESULTS:The test was positive in 519(89.9%)patients,with a greater response in EE patients(96.4%) compared with NERD patients(82.6%)(P=0.011). Both the percentage of completely asymptomatic patients,at 3 and 6 mo,and the reduction in heartburn intensity were significantly higher in the EE compared with NERD patients(P<0.01).Finally,the mean PGWBI score was significantly decreased before and increased after therapy in both subgroups when compared with the mean value in a reference Italian population. CONCLUSION:Our study confirms the validity of the Genval guidelines in the management of GERD patients. In addition,we observed that the overall response to PPI therapy is lower in NERD compared to EE patients.

Possible contribution of artificial neural networks and linear discriminant analysis in recognition of patients with suspected atrophic body gastritis

AIM: To investigate whether ANNs and LDA could recognize patients with ABG in a database, containing only clinical and biochemical variables, of a pool of patients with and without ABG, by selecting the most predictive variables and by reducing input data to the minimum.METHODS: Data was collected from 350 consecutive outpatients (263 with ABG, 87 with non-atrophic gastritis and/or celiac disease [controls]). Structured questionnaires with 22 items (anagraphic, anamnestic, clinical, and biochemical data) were filled out for each patient. All patients underwent gastroscopy with biopsies. ANNs and LDA were applied to recognize patients with ABG.Experiment 1: random selection on 37 variables, experiment 2: optimization process on 30 variables, experiment 3:input data reduction on 8 variables, experiment 4: use of only clinical input data on 5 variables, and experiment 5:use of only serological variables.RESULTS: In experiment 1, overall accuracies of ANNs and LDA were 96.6% and 94.6%, respectively, for predicting patients with ABG. In experiment 2, ANNs and LDA reached an overall accuracy of 98.8% and 96.8%,respectively. In experiment 3, overall accuracy of ANNs was 98.4%. In experiment 4, overall accuracies of ANNs and LDA were, respectively, 91.3% and 88.6%. In experiment 5, overall accuracies of ANNs and LDA were,respectively, 97.7% and 94.5%.CONCLUSION: This preliminary study suggests that advanced statistical methods, not only ANNs, but also LDA,may contribute to better address bioptic sampling during gastroscopy in a subset of patients in whom ABG may be suspected on the basis of aspecific gastrointestinal symptoms or non-digestive disorders.

Artifi cial neural networks in the recognition of the presence of thyroid disease in patients with atrophic body gastritis

AIM: To investigate the role of artifi cial neural networks in predicting the presence of thyroid disease in atrophic body gastritis patients. METHODS: A dataset of 29 input variables of 253 atrophic body gastritis patients was applied to artifi cial neural networks (ANNs) using a data optimisation procedure (standard ANNs,T&T-IS protocol,TWIST protocol). The target variable was the presence of thyroid disease. RESULTS: Standard ANNs obtained a mean accuracy of 64.4% with a sensitivity of 69% and a specifi city of 59.8% in recognizing atrophic body gastritis patients with thyroid disease. The optimization procedures (T&T-IS and TWIST protocol) improved the performance of the recognition task yielding a mean accuracy,sensitivity and specifi city of 74.7% and 75.8%,78.8% and 81.8%,and 70.5% and 69.9%,respectively. The increase of sensitivity of the TWIST protocol was statistically signifi cant compared to T&T-IS. CONCLUSION: This study suggests that artificial neural networks may be taken into consideration as a potential clinical decision-support tool for identifying ABG patients at risk for harbouring an unknown thyroid disease and thus requiring diagnostic work-up of their thyroid status.

Pre-endoscopic screening for Helicobacter pylori and celiac disease in young anemic women

AIM： To evaluate the usefulness of pre-endoscopic serological screening for He//cobacter py/or/ （H py/or/} infection and celiac disease in women aged 〈 50 years affected by iron-deficiency anemia （IDA）. METHODS： One hundred and fifteen women aged 〈 50 years with IDA were tested by human recombinant tissue transglutaminase IgA antibodies （tTG） and anti-H pylori IgG antibodies, tTG and H pylori IgG antibody were assessed using an enzyme-linked immunosorbent assay （ELISA）. All women were invited to undergo upper GI endoscopy. During gastroscopy, biopsies were collected from antrum （n = 3）, gastric body （n = 3） and duodenum （n = 4） in all patients, irrespective of test results. The assessment of gastritis was performed according to the Sydney system and celiac disease was classified by Marsh＇s System. RESULTS： 45.2% women were test-positive： 41 patients positive for H pylori antibodies, 9 patients for tTG and 2 patients for both. The gastroscopy compliance rate of test-positive women was significantly increased with respect to those test- negative （65.4% vs 42.8%; Fisher test P = 0.0239）. The serological results were confirmed by gastroscopy in 100% of those with positive H pylori antibodies, in 50% of those with positive tTG and in 81.5% of test- negative patient. Sensitivity and specificity were 84.8% and 100%, respectively for Hpylori infection and, 80% and 92.8% for tTG. Twenty-eight patients had positive H pylori antibodies and in all the patients, an active Hpylori infection was found. In particular, in 23 out of 28 （82%） patients with positive H pylori antibodies, a likely cause of IDA was found because of the active inflammation involving the gastric body. CONCLUSION： Anti-H pylori IgG antibody and tTG IgA antibody testing is able to select women with IDA to submit for gastroscopy to identify H pylori pangastritis and/or celiac disease, likely causes of IDA.

High-fibre diet and Lactobacillus paracasei B21060 in symptomatic uncomplicated diverticular disease

AIM： To investigate in symptomatic uncomplicated di- verticular disease the efficacy of symbiotics associated with a high-fibre diet on abdominal symptoms. METHODS： This study was a multicentre, 6-too ran- domized, controlled, parallel-group intervention with a preceding 4-wk washout period. Consecutive out- patients with symptomatic uncomplicated diverticular disease, aged 40-80 years, evaluated in 4 Gastroenterology Units, were enrolled. Symptomatic uncomplicated diverticular disease patients were randomized to two treatment arms A or B. Treatment A （n = 24 patients） received 1 symbiotic sachet Flortec~ （Lactobacillus paracasei B21060） once daily plus high-fibre diet for 6 mo. Treatment B （n = 21 patients） received high-fibre diet alone for 6 rno. The primary endpoint was regres- sion of abdominal symptoms and change of symptom severity after 3 and 6 mo of treatment. RESULTS： In group A, the proportion of patients with abdominal pain 〈 24 h decreased from 100% at base- line to 35% and 25% after 3 and 6 mo, respectively （P 〈 0.001）. In group B the proportion of patients with this symptom decreased from 90.5% at baseline to 61.9% and 38.1% after 3 and 6 mo, respectively （P = 0.001）. Symptom improvement became statistically sig- nificant at 3 and 6 mo in group A and B, respectively. The proportion of patients with abdominal pain 〉24 h decreased from 60% to 20% then 5% after 3 and 6 too, respectively in group A （P 〈 0.001） and from 33.3% to 9.5% at both 3 and 6 mo in group B （P = 0.03）. In group A the proportion of patients with ab- dominal bloating significantly decreased from 95% to 60% after 3 mo, and remained stable （65%） at 6-mo follow-up （P = 0.005） while in group B, no significant changes in abdominal bloating was observed （P = 0.11）. After 6 mo of treatment, the mean visual analogic scale （VAS） values of both short-lasting abdominal pain （VAS, mean ± SD, group A： 4.6 ± 2.1 vs 2.2 ± 0.8, P = 0.02; group B： 4.6 ± 2.9 vs 2.0 ± 1.9, P = 0.03） and abdom- inal bloating （VAS, mean ± SD, group A： 5.3 ± 2.2 vs 3.0 ± 1.7, P = 0.005; group B： 5.3 ±3.2 vs 2.3 ± 1.9, P = 0.006） decreased in both groups, whilst the VAS values of prolonged abdominal pain decreased in the Flortec group, but remained unchanged in the high-fibre diet group （VAS, mean ± SD, group A： 6.5 ± 1.5 vs 4.5 ± 2.1, P = 0.052; group B： 4.5 ± 3.8 vs 5.5 ± 3.5）. CONCLUSION： A high-fibre diet is effective in relievingabdominal symptoms in symptomatic uncomplicated di- verticular disease. This treatment may be implemented by combining the high-fibre diet with Flortec~.