Gastroesophageal Reflux Disease

Reflux gastro-œsophagien : évaluation de l'acupuncture

1. Systematic Reviews and Meta-Analysis

☆☆☆	Evidence for effectiveness and a specific effect of acupuncture
☆☆	Evidence for effectiveness of acupuncture
☆	Limited evidence for effectiveness of acupuncture
Ø	No evidence or insufficient evidence

1.1. Generic Acupuncture

1.1.1. Woo 2023

Woo JY, Pikov V, Chen JDZ. Neuromodulation for Gastroesophageal Reflux Disease: A Systematic Review. J Transl Gastroenterol. 2023;1(1):47-56. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10673618/

Background and objectives	In this systematic review, we evaluated the efficacy, mechanisms and safety of three neuromodulation therapies in patients with gastroesophageal reflux disease (GERD), including the effect of neuromodulation therapies on symptoms and key GERD pathophysiologies, lower esophageal sphincter (LES) pressure, esophageal motility, gastric motility, and parasympathetic activity. The first therapy is LES electrical stimulation using an implantable electrical stimulator, the second is transcutaneous electrical acustimulation, and the third is manual acupuncture.
Methods	A systematic review of literature according to the PRISMA guidelines was performed. Online databases searched include Medline (Ovid), Embase, and PubMed. Studies were assessed for inclusion and exclusion criteria with Covidence, a systematic review software.
Results	The analysis included thirteen clinical studies. Four papers included were registered under two open-label trials on ClinicalTrials.gov for LES electrical stimulation; Five randomized trials with sham-treated controls were analyzed for transcutaneous electrical acustimulation; Four studies, including three involving standard therapy controls and one involving shamtreated controls were included for manual acupuncture. All evaluated studies demonstrated significant beneficial effects on GERD symptoms, using patient-completed questionnaires, objective 24-h measurement of esophageal pH, and patient-reported use of proton pump inhibitors. In evaluating the effect on key GERD pathophysiologies, electrical stimulation significantly increased LES pressure, and transcutaneous electrical acustimulation significantly improved esophageal motility, gastric motility, and parasympathetic activity. None of the evaluated neuromodulation methods produced severe adverse effects.
Conclusions	Cumulative evidence from the evaluated studies indicates that neuromodulation therapies were effective in treating the GERD symptoms and key underlying GERD pathophysiologies. They are thus valuable options for individualized GERD treatment.

1.1.2. Yi 2020

Yi Yue et al. [Systematic Evaluation of Acupuncture and Combined Therapies for Treating Reflux Esophagitis]. Journal of Nanjing University of TCM. 2020. [212921].

Objective	To systematically evaluate the efficacy of acupuncture in reflux esophagitis (RE).
Methods	Based on retrieving the clinical randomized controlled studies on acupuncture treatment of RE in CNKI, WANFANG, VIP, CBM, PubMed, Embase and Cochrane Library databases up to May 2019, the related literature was extracted and evaluated with Meta-analysis on Rev Man5. 3.
Results	A total of 13 studies with 1 120 patients were included. In terms of reducing the recurrence rate, acupuncture alone or combination of acupuncture and medicine was superior to Western medicine [acupuncture alone: RR=0. 21, 95%CI (0. 05, 0. 87); acupuncture + Liujun Shugan Decoction: RR=0. 44, 95%CI (0. 27, 0. 71); acupuncture + Banxia Xiexin Decoction: RR=0. 29, 95%CI (0. 14, 0. 60); acupuncture + Xuanfu Daizhe Decoction and Zuojin Pill: RR=0. 40, 95%CI (0. 26, 0. 62); acupuncture + self-prescribed Chinese medicine + microwave hyperthermia: RR=0. 24, 95%CI (0. 08, 0. 66)]. In terms of endoscopic efficiency, electroacupuncture combined with Western medicine was better than Western medicine alone[RR=1. 23, 95%CI (1. 06, 1. 41)]. In terms of reducing the symptom scores, the combination of acupuncture and medicine was more effective than Western medicine [acupuncture + Chinese medicine: RR=-1. 73, 95%CI (-3. 21, -0. 25), acupuncture + Chinese medicine + Western medicine: RR=-4. 93, 95%CI (-5. 52, -4. 34)]. The adverse reactions of acupuncture combined with medicine were less than those of Western medicine alone.
Conclusion	In the treatment of RE, acupuncture combined with medicinal could obtain higher efficacy and lower recurrence while the efficacy of acupuncture alone is still unclear. Thus, there is an urgent need to standardize the efficacy of acupuncture in the treatment of RE and improve the quality of research. More high-quality randomized controlled trials are still needed in the future to validate the effectiveness of acupuncture for RE.

1.1.3. Wu 2019 ☆

Wu Xuhan, Li Guangyao, Qiu Ziyin, Liao Junming, Ge Heng, Chai Tiequ. [Systematic Review and Meta-analysis on Effect of Acupuncture-moxibustion in Treatment of Gastroesophageal Reflux Disease]. Liaoning Journal of Traditional Chinese Medicine. 2019;2:241-247. [201734].

Objective	To evaluate the clinical efficacy of acupuncture and moxibustion on gastroesophageal reflux disease by systematic review and Meta-analysis on the treatment of gastroesophageal reflux disease by acupuncture and moxibustion.
Methods	The databases including Cochrane Library, PubMed, Embase, CNKI,VIP and WanFang Databases were retrieved with computer for collecting RCT/CCT literature from database establishing time to Oct.2017.Using the standard provided by Cochrane5.1.0,quality evaluation and cheap risk assessment were carried out for the included studies, and statistical analysis was performed by using Revman5.3 software.
Results	There were totally 26 studies, involving 20155 samples（E:1087/C:1068）.The results:（1）The total effective rate of acupuncture combined with or without western medicine in the treatment of gastroesophageal reflux disease was higher than that in the western medicine group(OR=3.26,95%CI[2.53,4.21],P<0.01).（2）The recurrence rate of gastroesophageal reflux disease treated by acupuncture combined with or without western medicine was lower than that of Western medicine group(OR=0.24,95%CI[0.16,0.36],P<0.01).（3）In the improvement of symptom score, acupuncture combined with or without western medicine was superior to western medicine group in the treatment of gastroesophageal reflux disease(SMD=0.62,95%CI[0.41,0.84],P<0.01).（4）There was no difference between acupuncture combined with or without western medicine and pure western medicine in patients’ gastroscopy grading improvement(SMD=0.12,95%[-0.06,0.30],P=0.18>0.05).（5）Acupuncture combined with or without western medicine was superior to western medicine in the improvement of anxiety state of patients (SMD=1.62,95%CI[1.35,1.89],P<0.01).
Conclusion	Meta-analysis showed that the total effective rate, recurrence rate, symptom score, anxiety state, acupuncture and moxibustion were positive. The improvement of endoscopic mucosa in the experimental group and the control group was similar, but due to the overall low quality of the literature, more large samples were needed. Multicenter, high quality randomized controlled trials can support the results of this study.

1.1.4. Zhu 2017 ☆

Zhu J, Guo Y, Liu S, Su X, Li Y, Yang Y, Hou L, Wang G, Zhang J, Chen JJ, Wang Q, Wei R, Wei W. Acupuncture for the treatment of gastro-oesophageal reflux disease: a systematic review and meta-analysis. Acupunct Med. 2017;35(5):316-323. [100077].

Background	Gastro-oesophageal reflux disease (GORD) is one of the most common diseases presenting to gastroenterology clinics. Acupuncture is widely used as a complementary and alternative treatment for patients with GORD.
ObjectivE	To explore the effectiveness of acupuncture for the treatment of GORD.
Methods	Four English and four Chinese databases were searched through June 2016. Randomised controlled trials investigating the effectiveness of manual acupuncture or electroacupuncture (MA/EA) for GORD versus or as an adjunct to Western medicine (WM) were selected. Data extraction and quality evaluation were performed by two authors independently and RevMan 5.2.0 was used to analyse data.
Results	A total of 12 trials involving 1235 patients were included. Meta-analyses demonstrated that patients receiving MA/EA combined with WM had a superior global symptom improvement compared with those receiving WM alone (relative risk (RR) 1.17, 95% CI 1.09 to 1.26; p=0.03; six studies) with no significant heterogeneity (I2=0%, p=0.41). Recurrence rates of those receiving MA/EA alone were lower than those receiving WM (RR 0.42,95% CI 0.29 to 0.61; p<0.001; three studies) with low heterogeneity (I 2=7%, p=0.34), while global symptom improvement (six studies) and symptom scores (three studies) were similar (both p>0.05). Descriptive analyses suggested that acupuncture also improves quality of life in patients with GORD.
Conclusion	This meta-analysis suggests that acupuncture is an effective and safe treatment for GORD. However, due to the small sample size and poor methodological quality of the included trials, further studies are required to validate our conclusions.

1.2. Special Acupuncture Techniques

1.2.1. Combination with traditional Chinese medicine

1.2.1.1. Li 2018 ☆

Li Guangyao, Wu Xuhan, Liao Junming, Ge Heng, Li Min. [Systematic evaluation and Meta-analysis of acupuncture combined with traditional Chinese medicine in the treatment of gastroesophageal reflux disease]. Tianjin Journal of Traditional Chinese Medicine. 2018;10:756-761. [181302].

Objective	Acupuncture combined with Chinese medicine in the treatment of gastroesophageal reflux disease were systematically evaluated and Meta-analysis to explore the clinical efficacy of acupuncture combined with Chinese medicine on gastroesophageal reflux disease.
Methods]	The documents were searched from Cochrane Library, PubMed, CNKI, VIP and WANFANG. The relevant randomized controlled trial/semi-randomized controlled trial were collected from the first year that the database was established to October 2017. The quality evaluation and risk assessment of the inclusion were carried out using the criteria provided by the Cochrane5.1.0, and the effective rate, recurrence rate, plasma mot and symptom score of the treatment of gastroesophageal reflux disease were statistically analyzed by using the Revman 5.3 software.
Results	A total of 18 articles were included. The meta-analysis showed that: 1) The total effective rate of acupuncture and moxibustion combined with Chinese medicine in the treatment of gastroesophageal reflux disease was higher than that of Western medicine group(OR=3.14, 95%CI [2.24, 3.40], P<0.01). 2)The recurrence rate of gastroesophageal reflux disease treated by acupuncture combined with Chinese medicine was lower than that of western medicine group(OR =0.31, 95% CI [0.14, 0.68], P <0.01);(3)The improvement of plasma MOT in patients with acupuncture and moxibustion combined with Chinese medicine is superior to Western medicine(SMD=61.02, 95%CI [44.18, 77.87], P<0.01). 4) Patients with symptom score improvement, acupuncture combined with Chinese medicine group was better than Western medicine group(SMD =2.99, 95% CI[1.58, 4.39], P <0.01).
Conclusion	In the aspects of total effective rate, recurrence rate, symptom improvement and plasma MOT, acupuncture combined with Chinese medicine is effective.

1.2.2. Catgut Embedding

1.2.2.1. Song 2020

Song Qingzeng. [Meta-analysis of Gastroesophageal Reflux Disease Treated by Acupuncture and Acupoint Catgut Embedding on Governor Vessel]. Chinese Journal of Basic Medicine in TCM. 2020. [212913].

Objective	To evaluate the clinical efficacy and safety of acupuncture and acupoint catgut embedding on Governor Vessel in treating GERD.
Methods	Randomized controlled trials (RCTs) of acupuncture and acupoint catgut embedding in treating GERD were retrieved from the CNKI, VIP, Wanfang and Pubmed. The required literature were screened and extracted by two evaluators and the Meta-analysis was performed by RevMan 5. 3 software.
Results	A total of 6 trials involving 348 patients were included. Meta-analysis showed that the effect rate, cure rate and improving patient's symptoms of acupuncture and acupoint catgut embedding on Governor Vessel in treating GERD were both higher than those of control group.
Conclusion	Acupuncture and acupoint catgut embedding play a role in the treatment of GERD by stimulating acupoint of Governor Vessel are and the efficacy is better than that of the simple drug therapy in treating GERD. However, since the quality of the included literature is generally low and the number is small, this conclusion still needs larger samples, higher quality and more standardized RCTs to further validate and support.

2. Clinical Practice Guidelines

2.1. Michigan medicine. University of Michigan (USA) 2013 ⊕

Gastroesophageal Reflux Disease (GERD). Guidelines for Clinical Care Ambulatory. Michigan medicine. University of Michigan. 2013:12P. [197560].

Acupuncture may also have some benefit, as one trial found this modality to be more effective than doubling the dose of a PPI in patients with non-erosive disease.

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