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Prof. Rocco Maurizio Zagari Università di Bologna Epidemiologia della malattia da reflusso gastro-esofageo: una prospettiva globale Ferrara 27 Settembre.

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Presentation on theme: "Prof. Rocco Maurizio Zagari Università di Bologna Epidemiologia della malattia da reflusso gastro-esofageo: una prospettiva globale Ferrara 27 Settembre."— Presentation transcript:

1 Prof. Rocco Maurizio Zagari Università di Bologna Epidemiologia della malattia da reflusso gastro-esofageo: una prospettiva globale Ferrara 27 Settembre 2014 Camera di Commercio, Largo Castello

2 Gastro-esophageal reflux disease (GERD) GERD is a DISEASE which develops when the reflux of gastric content causes troublesome symptoms or complications

3 The Montreal Definition and Classification of Gastroesophageal Reflux Disease, AJG 2006 GERD is a condition which develops when the reflux of gastric content causes troublesome symptoms or complications

4 Gastroesofageal Reflux Disease A major public health concern A global chronic disease Costly, with a significant negative impact on quality of life Associated with esophageal adenocarcinoma Epidemiology of GERD: not an easy task Few well designed epidemiological studies in the general population

5 The Montreal Definition and Classification of Gastroesophageal Reflux Disease, AJG 2006 GERD is a condition which develops when the reflux of gastric content causes troublesome symptoms or complications In population-based studies, GERD is defined by heartburn and/or regurgitation – occurring at least 2 days per week, if mild, or at least 1 day per week, if moderate / severe

6 Population-based studies of the incidence of GERD-symptoms El-Serag et al. GUT 2014

7 Worldwide prevalence of GERD-symptoms El-Serag et al. GUT 2014

8 Worldwide time-trend prevalence of GERD-symptoms Date of publication Prevalence Bazzoli F, DDW 2012

9 Poisson regression analysis of trends in the prevalence of GERD worldwide El-Serag et al. GUT 2014

10 Changes in prevalence of GERD-symptoms from to by sex in Norway The prevalence of at least weekly GERD-symptoms increased by 47% (from 11.6% to 17.1%) Ness-Jensen et al. GUT 2011

11 Everhart JE & Constance ER. Gastroenterology 2009 Esophageal cancer Age-adjusted incidence rates in the U.S.

12 Estimates based on symptom surveys alone may under-diagnose true GERD prevalence. Only endoscopy can identify asymptomatic subjects with reflux esophagitis or Barrett’s esophagus. Reflux symptom-based and endoscopic diagnoses of GERD provide complementary information for epidemiological research. Very few large-scale endoscopic studies in the general population have been carried out so far. Limitations of reflux symptom-based epidemiological studies

13 High prevalence of gastroesophageal reflux symptoms and esophagitis with or without symptoms in the general adult Swedish population: the Swedish Kalixanda study. Ronkajnen et al, Scand J Gastroenterol 2005 Gastro-oesophageal reflux symptoms, oesophagitis and Barrett’s oesophagus in the general population: the Italian Loiano–Monghidoro study Zagari et al, GUT 2008 Epidemiology of symptom-defined gastroesophageal reflux disease and reflux esophagitis: the Chinese SILC study. Zou et al, Scand J Gastroenterol 2011 Endoscopic studies in the general population

14 Large-scale endoscopic surveys in the general population Prevalence of symptom-defined GERD

15 Prevalence of different types of endoscopic findings in the general population %

16 Dent J et al. Clin Gastroenterol Hepatol 2012 Prevalence of esophagitis by severity in the general population

17 Prevalence of esophagitis in individuals with or without symptoms of GERD in the general population

18 Proportion of individuals with esophagitis who do not have symptoms of GERD in the general population

19 Diagnostic Features of Barrett’s Esophagus Spechler SJ. NEJM 2014

20 ESEM: endoscopically suspected esophageal metaplasia SIM: Specialized intestinal metaplasia Prevalence of Barrett’s esophagus in the general population

21 Prevalence of Barrett’s esophagus in individuals with or without symptoms of GERD in the general population

22 ESEM SIM Kalixanda ESEM SIM Loiano Monghidoro ESEM SIM SILC Proportion of individuals with Barrett’s oesophagus who do not have symptoms of GERD in the general population

23 True prevalence of GERD Kalixanda Loiano Monghidoro SILC Subjects n GERD symptoms28.1%25.9%4.7% NO GERD symptoms Esophagitis12.1%8.6%6.1% Barrett - SIM1.9%0.8%N/A True prevalence42.1%35.3%-- Large-scale endoscopic surveys in the general population

24 Screening for Barrett’s Esophagus In patients with GERD and multiple risk factors for Barrett’s esophagus and esophageal adenocarcinoma screening for Barrett’s esophagus is suggested: Risk factors: Age > 50 years, male sex, white race, obesity and smoking In patients with GERD and multiple risk factors for Barrett’s esophagus and esophageal adenocarcinoma screening for Barrett’s esophagus is suggested: Risk factors: Age > 50 years, male sex, white race, obesity and smoking Screening all patients with GERD for Barrett’s esophagus is NOT recommended (strong recommendation, low-quality evidence) AGA Guidelines, Gastroenterology 2011 (week recommendation, moderate-quality evidence)

25 The incidence of esophageal cancer and high-grade dysplasia in Barrett’s esophagus A Systematic Review and Meta-analysis Pooled estimate Per 100 person-yearsPerson-years Cancer0.391 in 256 Cancer and high-grade dysplasia in 130 Yousef et al Am J Epidemiol 2008

26 Surveillance of Barrett’s esophagus Endoscopic surveillance should be performed in patients with Barrett’s esophagus with the following surveillance intervals: Barrett’s esophagus: 3 – 5 years Low-grade dysplasia: 6 –12 months High-grade dysplasia in absence of eradication therapy: 3 months (weak recommendation, low-quality evidence) AGA – Guidelines 2011 Spechler SJ. NEJM 2014

27 Risk and protective factors for GERD Hiatus Hernia Overweight / Obesity Age Gender Genetic Cigarette smoking Alcohol consumption Drugs intake Helicobacter pylori Physical activity Risk factorsProtective factors

28 Hiatus hernia and GERD in endoscopic-based population studies Hiatus Hernia is significantly associated with an increased risk of: Ronkainen et al. Scand J Gastroenterol 2005 Ronkainen et al. Gastroenterology 2005 Zagari et al. GUT 2008 Frequent reflux symptoms Esophagitis Barrett’s esophagus

29 Prevalence of Hiatus hernia in the general population

30 Jacobson BC et al, NEJM 2006 BMI and the risk of GERD symptoms

31 El-Serag H. Dig Dis Sci 2008 GERD symptomsEsophagitis Esophageal Adenocarcinoma Barrett Esophagus Hampel et al. Ann Intern Med 2005 El-Serag H. Dig Dis Sci 2008 Kamat et al. Ann Thorac Surg 2009 Obesity and GERD: a positive association

32 Wang et al, Lancet 2011 Past and projected prevalence of overweight (BMI ≥25 kg/m 2 )

33 Esophageal adenocarcinoma GERD symptoms H.pylori and GERD: a negative association Fischbach et al. Helicobacter 2012 Zhou et al. Clin Oncol 2008 Raghunath et al. BMJ 2003 Barrett’s esophagus

34 Helicobacter pylori and GERD Ghoshal et al. JNM 2010

35 Before chemoprevention After chemoprevention Subjects n Atrophic gastritis1056 (59.9%)115 (13.7%) Peptic ulcer193 (11.0%)30 (3.6%) Reflux oesophagitis241 (13.7%)230 (27.3%) Lee et al. GUT 2013 Prevalence of gastric and oesophageal lesions before and after mass eradication of H. pylori in Shangai

36 Worldwide prevalence of H.pylori infection Bauer et al. Ulcers 2011

37 Negative linear association between prevalence of esophagitis and prevalence of H. pylori in the general population Pearson’s correlation coefficient, r = Zagari RM, Unpublished 2014

38 Time trend of H. pylori infection prevalence Eastern Europe Western Europe Goh et al. APT 2008 Grad et al. Am J Epidemiol 2011 Miendje Deyi et al. Epidemiol Infect 2011

39 In USA and Europe GERD seems to be an “endemic disease” with a prevalence of about 30-40% in the general population. The prevalence of GERD is still increasing in western countries and it is now clearly rising also in Asia A substantial proportion of subjects with esophagitis or Barrett’s esophagus are free of GERD symptoms. The changing epidemiology of GERD correlates with changing epidemiology of the most important associated factors, such as obesity and Helicobacter pylori. Conclusions

40 Prevalence of esophagitis in the general population


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