Understanding GERD symptoms in the clinical setting

Gastroesophageal reflux disease (GERD) is a highly prevalent disorder which affects 10-30% of the population in Western countries. It is associated with risk of Barrett's esophagus and adenocarcinoma, although the risk is limited and many patients do not have progressive disease. Identification and treatment of GERD symptoms is the main target for the majority of patients with this disease. Since the grading of lesions and symptoms are two independent indicators of disease severity, these two main characteristics for GERD evaluation should be considered separately. Proper symptom assessment as a measure of the severity of disease and for the evaluation of treatment response is required, as are symptom assessment tools for practical clinical use.Holtmann, G.http://www.ncbi.nlm.nih.gov/pubmed/1620022

Hypothesis driven research and molecular mechanisms in functional dyspepsia: The beginning of a beautiful friendship in research and practice?

There is accumulating evidence of a genetic predisposition in at least a subset of patients with functional GI symptoms. Hence, hunting for genes in irritable bowel syndrome and functional dyspepsia has become fashionable of late. Unfortunately, as in other fields, replication of gene association studies has most often been problematic. In this issue of the Journal, independent corroboration of an association of dyspepsia with GNbeta3 is reported. Other carefully selected putative genes including polymorphisms in the alpha2A adrenoreceptor, the serotonin reuptake transporter, and the 5-HT1A receptor were not associated. The study raises three key questions all considered in this editorial: (a) if GNbeta3 is truly associated with functional and uninvestigated dyspepsia, why might this be the case, (b) what molecular mechanisms may be of most relevance, and (c) perhaps most importantly, does or will this finding translate into clinical practice in terms of diagnosis or treatment? New knowledge of gene associations like GNbeta3 and their pathophysiological relevance may ultimately lead to better targeted therapy as well as new disease modifying treatments.Gerald Holtmann and Nicholas J. Talle

Irritable bowel syndrome

© Georg Thieme Verlag Stuttgart · New YorkPatients with irritable bowel syndrome (IBS) are highly prevalent among subjects seeking medical attention at the general practitioner or specialist level. While IBS lacks any disease associated excess mortality, this disorders is relevant to the affected subjects due to the considerable burden with regard to the symptoms and an impaired quality of life. Furthermore, this disease has a substantial impact on society due to the economical consequences. In recent years substantial progress has been achieved regarding our pathophysiological understanding. However, as usual, there has been a substantial delay between the discovery of disease mechanisms and its translation into improved patient care. For diagnosing IBS standardized criteria have been established (i. e. Rome II- or the DGVS-criteria). Regarding treatment, life style advice such as avoidance of specific nutrients that precipitate or aggravate or the "little psychotherapy" (addressing patients concerns and anxiety regarding the symptoms) are considered essential. However, the overall response rate is disappointing. Evidence-based pharmacological interventions include herbal preparations, spasmolytics, low dose tricyclic antidepressants and 5-HT-3-receptor antagonists and 5-HT-4-receptor agonists. At present no cure for patients with IBS exists. Thus, all currently available treatments target palliation of symptoms. This, however, may change in the future.B. Adam, T. Liebregts, G. Holtman

Evidence-based medicine and phytotherapy for functional dyspepsia and irritable bowel syndrome: a systematic analysis of evidence for the herbal preparation Iberogast

Functional gastrointestinal disorders like functional dyspepsia and irritable bowel syndrome are characterized by more or less specific symptoms and the absence of structural lesions to explain symptoms. Other studies suggest that abnormalities of specific gut function are linked to manifestation of symptoms. These abnormalities include disturbances of motility such as postprandial fundic relaxation, gastric emptying and disturbed visceral sensory function. The underlying pathophysiology is not fully understood. However, various studies point towards hereditary (or molecular) factors modified by environmental factors. Considering this broad spectrum of factors it is conceivable that treatments targeting a single mechanism are most likely to improve symptoms only in patients with a disturbance linked to this mechanism. Thus overall efficacy in the whole patient population is limited. Indeed, superiority of chemically defined treatments targeting a single receptor yield a benefit over placebo of between 10 and 15%. In recent years well-controlled studies have demonstrated superiority of specific herbal preparations. This in particular held true for combinations of various plant extracts or herbal extracts with a number of different active ingredients. However, efficacy of herbal treatment for functional GI disorders cannot be taken for granted and these drugs need to be rigorously tested for efficacy and safety. In this context, same standards apply as for conventional chemically defined medications.Holtmann, G; Adam, B and Vinson, B

Genetic disorders in gastroenterology and hepatology - Susceptibility genes and functional gastrointestinal disorders

Article first published online: 12 OCT 2005T Liebregts, B Adam and G Holtman

Guidance on the use of over-the-counter proton pump inhibitors for the treatment of GERD

Objective: The aim of this paper was to develop a guideline on the over-the-counter management of gastroesophageal reflux disease with proton pump inhibitors (i.e. omeprazole). Setting A meeting of internationally renowned gastroenterologists in January 2009, in Berlin, Germany. Methods: An expert panel group of gastroenterologists convened to develop a consensus-based algorithm for pharmacists for over-the-counter (OTC) treatment with proton pump inhibitors (PPIs). Key considerations were the short-term safety and efficacy of PPIs, and the extent of the risk to the sufferer, owing to the treatment not being controlled by a physician. Main outcome measures A consensus- based treatment algorithm for the OTC management of gastroesophageal reflux disease and evidence- based guidance on the use of OTC PPIs. Results: As defined by the treatment algorithm, the pharmacist should first confirm the diagnosis based on the presence of typical symptoms and secondly, as a result, rule out general practitioner referral. The third step focuses on the nature, severity and frequency of the symptoms—the patients who might have the highest benefit from a short course (14 days) of OTC PPIs are those with less than three episodes of heartburn and/or acid regurgitation per week. Patients who have three or more episodes per week can use the OTC PPIs but should also be encouraged to visit a physician, and those who already have a diagnostic workup can use proton pump inhibitors as rescue treatment if they are known responders. Guidance for pharmacists, in the form of questions and answers, summarises the current published clinical experience with PPIs in terms of their efficacy and safety, and optimal treatment schedule. Conclusions: Gastroesophageal reflux disease imposes a considerable burden on sufferers. Owing to their accepted efficacy and safety, PPIs are becoming popular as OTC options for the treatment of gastroesophageal reflux disease symptoms such as heartburn and acid regurgitation. Effective self-management of gastroesophageal reflux disease with OTC PPIs, e.g. omeprazole, could lead to lasting freedom from symptoms and improved quality of life for sufferers.Gerald Holtmann, Marc-André Bigard, Peter Malfertheiner and Roy Pounde

Intraoperative cholangioscopy in the management of biliary adenomas

Article first published online: 26 JAN 2004Georgios C. Sotiropoulos, Hauke Lang, Gerald Holtmann and Christoph E. Broelsc

Review article: From gastrin to gastro-oesophageal reflux disease - a century of acid suppression

Copyright (C) 2006 Blackwell Publishing Ltd