Management of Reflux Oesophagitis: Role of Weight Loss and Cimetidine F. E. Murray, J. Ennis, J. R. Lennon, J. P. Crowe*
Division of Gastroenterology and Department of Radiology, Mater Hospital, Dublin 7. Summary A double blind clinical trial was performed to evaluate the effect of weight loss and cimetldine in the treatment of reflux oesophagitis. Thirty-two patients were evaluated by endoscopy, L.O.S.P. determination, oesophageai sclntigraphy and ambulatory 24 hour oesophageal pH monitoring. Patients were randomly allocated into treatment using a regimen of placebo/weight loss or cimetidine/weight loss. Assessments were repeated after 8-12 weeks. A similar weight loss and improvement in symptoms and endoscopy appearances was seen in both groups. In contrast there was no significant change in frequency or duration of reflux on 24-hour pH monitoring or oesophageal scintigraphy or L.O.S.P. We conclude that weight loss may have an important role in the treatment of reflux oesophagitis and should be recommended to patients as an early therapeutic intervention. Cimetidine did not confer any additional benefit to that obtained from weight loss alone. Introduction It is frequently suggested that obesity may have a role in the aetiology of reflux oesophagitis. The possible mechanisms by which obesity may act in reflux oesophagitis sphincter (LOS), thus reducing the "squeeze" effect of diaphragmatic muscle in preventing reflux; increased fat deposition in the intra-abdominal cavity leading to increased intra-abdominal pressure; and elevated steroid hormone levels in obesity leading to reduction in LOS pressurea). Weight loss is usually recommended in the management of oesophagitis, although there are no controlled clinical studies to confirm its usefulness. The treatment of reflux oesophagitis is unsatisfactory. Well controlled clinical trials testing the efficacy of the commonly prescribed physiological measures and pharmacological agents used in the treatment of reflux oesophagitis have been slow in their evolution~24), and experimental support for their efficiency is scant. Most regimens advise weight reductiondemonstrated that obesity per se does not predispse to alteration in LOS pressure or length; in addition, they demonstrated that, 7-12 months following surgery for obesity resulting in an unquantified weight loss (amount not specified), the manometric characteristics of the LOS were unchanged. The mechanism of improvement in reflux oesophagitis in patients who lost weight is open to question. 6 of the 10 patients whose endoscopic appearance improved following weight loss demonstrated a reduction in gastro-oesophageal reflux on 24 hour ambulatory pH monitoring, suggesting that weight loss, per se, may reduce gastro-oesophageal reflux. Since there was little change in LOSP in these patients,
I.tgs.
January, 1991
another mechanism must be invoked, e.g. lowered intraabdominal pressure as a result of reduced intra-abdominal fat, or more effective "squeeze" action by diaphragm as a result of reduced fat. The value of cimetidine in this study was found to be equivalent to that of weight loss alone. In keeping with previous studies, we have found that symptoms of reflux oesophagitis are improved to a greater extent than signs following treatment with H2 antagonists. In conclusion, we have demonstrated that weight loss alone is as effective as cimetidine and weight loss in the treatment of reflux oesophagitis. This confLrms the clinical impression that weight loss has a role in the management of reflux oesophagitis. References 1. Jennewein, H. M., Waldeck, F., Siewen, R., Weiser, F., Thimm, R. The interaction of pentagastrin and glueagon at the lower oesophageal sphincter in man and dogs. Gut 1973: 14, 861-864. 2. Bennet, J. R., Buckton, G. K., Martin, H. D. Cimetidinn in gastro_oesophageal reflux. Digestion 1983: 26, 166-172. 3. Thanik, K. D., Chey, W. Y., Shah, A. S., Guttierrez, J. G. Reflux oesophagitis: Effect of oral bethanechol on symptoms and endoscopic findings. Ann. Int. Med. 1980: 93, 805-808. 4. Bright-Asare, P., El Bassonsi, M. Cimetidine, metoclopramide or placebo in reflux oesophagitis. Clin. Gastroenterol. 1980: 2, 149-156. 5. Bennett, J. R. Medical treatment of reflux oesophagitis. In: Reflux Oesophagitis, Eds. Hennessy, T. P. U., Cushieri, A., Bennett, J. R. Butterworths 1989: 123-142. 6. Fisher, R. S., Malmud, L.S., Roberts, G. S., Lobis, I. F. Gastroesophageal scintiscanning to detect and quantitate GE reflux. Gastroenterology 1976: 70, 301-8. 7. Dodds, W. J. Instrumentation and methods for intraluminal oesophageal manometry. Arch Int. Med. 1976: 136, 525-523. 8. Evans, D. F. 24-hour ambulatory oesophageal pH monitoring: an update. Br. J. Surg. 1987: 74, 157-161. 9. Sigmund, G. W., McNaUy, E. F. The action of a carminative on the lower oesophageal sphincter. Gastroenterology 1869: 56, 13-18. I0. Dennish, G. W., Castello, D.O. Inhibito~ effect of smoking on the lower oesophageal sphincter. N. Eng. J. Med. 1971: 284, 1136-1137. 11. Stanciu, C., Bennett, L R. The effect of smoking on gastroesophageal reflux. Gut 1972: 13, 318-325. 12. O'Brien, T. F., Stoop, E.M. Lower oesophageal sphineterpressure and oesophageal function in obese humans. J. Clin. Gastroenterol. 1980: 2, 145-149. 13. Backrnan, L., Granstom, L., l_.indahl, J., Mechler, A. Manometric studies of the lower oesophageal sphincter in extreme obesity. Acta Chir. Scand. 1983: 149, 197-1197.
Division of Gastroenterology and Department of Radiology, Mater Hospital, Dublin 7. Summary A double blind clinical trial was performed to evaluate the effect of weight loss and cimetldine in the treatment of reflux oesophagitis. Thirty-two patients were evaluated by endoscopy, L.O.S.P. determination, oesophageai sclntigraphy and ambulatory 24 hour oesophageal pH monitoring. Patients were randomly allocated into treatment using a regimen of placebo/weight loss or cimetidine/weight loss. Assessments were repeated after 8-12 weeks. A similar weight loss and improvement in symptoms and endoscopy appearances was seen in both groups. In contrast there was no significant change in frequency or duration of reflux on 24-hour pH monitoring or oesophageal scintigraphy or L.O.S.P. We conclude that weight loss may have an important role in the treatment of reflux oesophagitis and should be recommended to patients as an early therapeutic intervention. Cimetidine did not confer any additional benefit to that obtained from weight loss alone. Introduction It is frequently suggested that obesity may have a role in the aetiology of reflux oesophagitis. The possible mechanisms by which obesity may act in reflux oesophagitis sphincter (LOS), thus reducing the "squeeze" effect of diaphragmatic muscle in preventing reflux; increased fat deposition in the intra-abdominal cavity leading to increased intra-abdominal pressure; and elevated steroid hormone levels in obesity leading to reduction in LOS pressurea). Weight loss is usually recommended in the management of oesophagitis, although there are no controlled clinical studies to confirm its usefulness. The treatment of reflux oesophagitis is unsatisfactory. Well controlled clinical trials testing the efficacy of the commonly prescribed physiological measures and pharmacological agents used in the treatment of reflux oesophagitis have been slow in their evolution~24), and experimental support for their efficiency is scant. Most regimens advise weight reductiondemonstrated that obesity per se does not predispse to alteration in LOS pressure or length; in addition, they demonstrated that, 7-12 months following surgery for obesity resulting in an unquantified weight loss (amount not specified), the manometric characteristics of the LOS were unchanged. The mechanism of improvement in reflux oesophagitis in patients who lost weight is open to question. 6 of the 10 patients whose endoscopic appearance improved following weight loss demonstrated a reduction in gastro-oesophageal reflux on 24 hour ambulatory pH monitoring, suggesting that weight loss, per se, may reduce gastro-oesophageal reflux. Since there was little change in LOSP in these patients,
I.tgs.
January, 1991
another mechanism must be invoked, e.g. lowered intraabdominal pressure as a result of reduced intra-abdominal fat, or more effective "squeeze" action by diaphragm as a result of reduced fat. The value of cimetidine in this study was found to be equivalent to that of weight loss alone. In keeping with previous studies, we have found that symptoms of reflux oesophagitis are improved to a greater extent than signs following treatment with H2 antagonists. In conclusion, we have demonstrated that weight loss alone is as effective as cimetidine and weight loss in the treatment of reflux oesophagitis. This confLrms the clinical impression that weight loss has a role in the management of reflux oesophagitis. References 1. Jennewein, H. M., Waldeck, F., Siewen, R., Weiser, F., Thimm, R. The interaction of pentagastrin and glueagon at the lower oesophageal sphincter in man and dogs. Gut 1973: 14, 861-864. 2. Bennet, J. R., Buckton, G. K., Martin, H. D. Cimetidinn in gastro_oesophageal reflux. Digestion 1983: 26, 166-172. 3. Thanik, K. D., Chey, W. Y., Shah, A. S., Guttierrez, J. G. Reflux oesophagitis: Effect of oral bethanechol on symptoms and endoscopic findings. Ann. Int. Med. 1980: 93, 805-808. 4. Bright-Asare, P., El Bassonsi, M. Cimetidine, metoclopramide or placebo in reflux oesophagitis. Clin. Gastroenterol. 1980: 2, 149-156. 5. Bennett, J. R. Medical treatment of reflux oesophagitis. In: Reflux Oesophagitis, Eds. Hennessy, T. P. U., Cushieri, A., Bennett, J. R. Butterworths 1989: 123-142. 6. Fisher, R. S., Malmud, L.S., Roberts, G. S., Lobis, I. F. Gastroesophageal scintiscanning to detect and quantitate GE reflux. Gastroenterology 1976: 70, 301-8. 7. Dodds, W. J. Instrumentation and methods for intraluminal oesophageal manometry. Arch Int. Med. 1976: 136, 525-523. 8. Evans, D. F. 24-hour ambulatory oesophageal pH monitoring: an update. Br. J. Surg. 1987: 74, 157-161. 9. Sigmund, G. W., McNaUy, E. F. The action of a carminative on the lower oesophageal sphincter. Gastroenterology 1869: 56, 13-18. I0. Dennish, G. W., Castello, D.O. Inhibito~ effect of smoking on the lower oesophageal sphincter. N. Eng. J. Med. 1971: 284, 1136-1137. 11. Stanciu, C., Bennett, L R. The effect of smoking on gastroesophageal reflux. Gut 1972: 13, 318-325. 12. O'Brien, T. F., Stoop, E.M. Lower oesophageal sphineterpressure and oesophageal function in obese humans. J. Clin. Gastroenterol. 1980: 2, 145-149. 13. Backrnan, L., Granstom, L., l_.indahl, J., Mechler, A. Manometric studies of the lower oesophageal sphincter in extreme obesity. Acta Chir. Scand. 1983: 149, 197-1197.
