title: Control of acid and duodenogastroesophageal reflux (DGER) in patients with Barrett's esophagus.
abstract: OBJECTIVE
  Symptom eradication in patients with Barrett's esophagus (BE) does not guarantee control of acid or duodenogastroesophageal reflux (DGER). Continued reflux of acid and/or DGER may increase risk of neoplastic progression and may decrease the likelihood of columnar mucosa eradication after ablative therapy. To date, no study has addressed whether both complete acid and DGER control is possible in patients with BE. This prospective study was designed to assess the effect of escalating-dose proton pump inhibitor (PPI) therapy on esophageal acid and DGER.
  
  
  METHODS
  Patients with BE (≥3 cm in length) underwent simultaneous ambulatory prolonged pH and DGER monitoring after at least 1 week off PPI therapy followed by testing on therapy after 1 month of twice-daily rabeprazole (20 mg). In those with continued acid and/or DGER, the tests were repeated after 1 month of double-dose (40 mg twice daily) rabeprazole. The primary study outcome was normalization of both acid and DGER. Symptom severity was assessed on and off PPI therapy employing a four-point ordinal scale.
  
  
  RESULTS
  A total of 29 patients with BE consented for pH monitoring, of whom 23 also consented for both pH and DGER monitoring off and on therapy (83% male; mean age 58 years; mean body mass index 29; mean Barrett's length 6.0 cm). Median (interquartile range) total % time pH <4 and bilirubin absorbance >0.14 off PPI therapy were 18.4 (11.7-20.0) and 9.7 (5.0-22.2), respectively. In addition, 26/29 (90%) had normalized acid and 18/23 (78%) had normalized DGER on rabeprazole 20 mg. Among those not achieving normalization on 20 mg twice daily, 3/3 (100%) had normalized acid and 4/5 (80%) had normalized DGER on rabeprazole 40 mg twice daily. All subjects had symptoms controlled on rabeprazole 20 mg twice daily. Univariate analysis found no predictor for normalization of physiologic parameters based on demographics.
  
  
  CONCLUSIONS
  Symptom control does not guarantee normalization of acid and DGER at standard dose of twice-daily PPI therapy. Normalization of acid and DGER can be achieved in 79% of BE patients on rabeprazole 20 mg p.o. twice daily, and in the majority of the remainder at high-dose twice-daily PPI. In patients undergoing ablative therapy, pH or DGER monitoring may not be needed to ensure normalization of reflux if patients are treated with high-dose PPI therapy.
authors.affiliation: Division of Gastroenterology, Hepatology, and Nutrition, Vanderbilt University Medical Center, Nashville, Tennessee, USA.
authors.forename: Patrick
authors.initials: P
authors.lastname: Yachimski
authors.affiliation: Sutter Health, Sutter Medical Center, Sacramento, California, USA.
authors.forename: Sabba
authors.initials: S
authors.lastname: Maqbool
authors.affiliation: California Pacific Medical Center, San Francisco, California, USA.
authors.forename: Yasser M
authors.initials: YM
authors.lastname: Bhat
authors.affiliation: Department of Digestive Diseases and Nutrition, Joy McCann Culverhouse Center for Swallowing Disorders, University of South Florida Morsani College of Medicine, Tampa, Florida, USA.
authors.forename: Joel E
authors.initials: JE
authors.lastname: Richter
authors.affiliation: Division of Gastroenterology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA.
authors.forename: Gary W
authors.initials: GW
authors.lastname: Falk
authors.affiliation: Division of Gastroenterology, Hepatology, and Nutrition, Vanderbilt University Medical Center, Nashville, Tennessee, USA.
authors.forename: Michael F
authors.initials: MF
authors.lastname: Vaezi
mesh_terms: D000368:Aged; D001471:Barrett Esophagus / Q000188:drug therapy* / Q000209:etiology / Q000503:physiopathology; D001663:Bilirubin / Q000032:analysis; D003680:Deglutition Disorders / Q000209:etiology; D050782:Esophageal pH Monitoring; D005260:Female; D005764:Gastroesophageal Reflux / Q000150:complications / Q000188:drug therapy* / Q000503:physiopathology; D006356:Heartburn / Q000209:etiology; D006801:Humans; D006863:Hydrogen-Ion Concentration; D008297:Male; D008875:Middle Aged; D009325:Nausea / Q000209:etiology; D011446:Prospective Studies; D054328:Proton Pump Inhibitors / Q000008:administration & dosage*; D064750:Rabeprazole / Q000008:administration & dosage*; D012720:Severity of Illness Index; D014839:Vomiting / Q000209:etiology
chemical_list: D054328:Proton Pump Inhibitors; D064750:Rabeprazole; D001663:Bilirubin